Archive for September, 2009

What Can Claim Fraud-Fighters Learn from Dwight Schrute and “The Office”?

September 27, 2009

The latest episode (9/23/09) of the TV sitcom, “The Office” featured a subplot pertaining to workers compensation claim fraud.  Seems like Darryl down in the warehouse reported a back injury after falling off of a ladder while performing work duties.  Human Resources Director Toby accepts the story but Dwight Schrute smells a rat.  Many features of Darryl’s story do not make sense to Dwight, who urges Toby to investigate further.  Their homemade attempts to reenact Darryl’s accident deepen their suspicions and they plan a stake out near Darryl’s home while he convalesces on disability.

I won’t give away the plot at this point, except for the fact that the do-it-yourself attempt at surveillance and insurance claim fraud fighting ends up backfiring on the management team at Dunder-Mifflin.

“The Office” and the episode are pure fiction, but unfortunately workers compensation claim fraud is not.

Nevertheless, the episode of “The Office” illustrates a few valid points.

First, have a healthy dose of skepticism with regard to every report of on-the-job injury.   “Trust but verify” is a sound maxim.

Second, leave things like surveillance for the experts.  Amateurish attempts to undertake surveillance and fraud investigations may create new liabilities in addition to workers compensation costs.

Fighting claim fraud is a legitimate endeavor when there is a reasonable suspicion of dubious activity.  What is not reasonable is trying to shave costs and cut corners by undertaking amateurish DIY efforts at fighting fraud.

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Sometimes Low-Tech Tools are best for Adjuster Productivity and Effectiveness

September 14, 2009

Adjusters now have at their disposal all sorts of high-tech tools to presumably increase their productivity.  They have damage estimating software to calculate property loss.

They have Colossus software to help compute the value of bodily injury claims.  We have broadband Internet systems and computers that can calculate at warp speed.  We have calendar and organizational software to manage task lists and key dates.  We have Blackberries, iPhones, 3G smart phones and PDA’s.

These are all handy tools.  I confess to being a bit of a gadget freak and have often been accused of being an “early adopter” by others who were not totally sold on newfangled gizmos.

Sometimes we forget, though, that a key to productivity and effectiveness lies not in technology tools.  Rather, it may rely upon good old-fashioned willpower, the willingness to do things daily as claims professionals that we would really rather not do.  To do things that we would rather put off, delay or procrastinate on.

We don’t want to field that phone call from a difficult claimant who’s phoning for the umpteenth time, badgering us about the “low” damage estimates to her soot-stained kitchen.

We don’t want to deal with the building contractor who says he’s going to need an extra 20% to cover his increased material costs.

We don’t want to handle the difficult commercial account to is forever questioning our reserve numbers as being too high, and even when actuaries who review the same numbers criticize us for setting them too low.

We don’t want to negotiate with a belligerent claimant attorney who has a chip on his shoulder about adjusters and a poorly disguised distain for insurance companies.

We don’t want to leave a warm bed at 3:30 AM to drive 42 miles to stand next to a frigid isolated highway to oversee a tractor trailer accident.

These things we do, not because we want to do them that because they are sometimes the necessary components of being a claims adjuster.  The willingness to do them even when we don’t want to is a hallmark of a productive and effective adjuster; it has nothing to do with one’s technology tools.  To be sure, having a combination of high-tech tools and these character traits will comprise a formidable package in the adjuster’s effectiveness arsenal.

Bicycling champion Lance Armstrong titled his first book, “It’s Not About the Bike.”  His point was that his ability to overcome cancer and to win the Tour de France bicycle race was more due to his own persistence and character and willingness to pay the price it was because he had the most high-tech bicycle.

Yes, in time Lance Armstrong also became a student of bicycle racing technology.  As he began defending successive Tour de France titles, he would exhaustively test bicycle frames in wind titles, check the aerodynamics of various designs of bicycle helmets and even the aerodynamic properties of different types of fabrics next to his skin.  He overlooked no detail in either technology or his training to prepare himself for multiple defenses of his Tour de France yellow jersey.  It was not just about the bike but also about the bedrock character qualities that he exhibited to fight through, to pay the price and to do the unpleasant things that he didn’t want to do — – even if that meant 115 mile training ride through cold rain when he would rather be lounging on the sofa.

As motivational sage Randy Gage has stated as a daily mantra, “I’ll do today what others won’t so I can do tomorrow what others can’t.”

It’s not about the bike and it’s not about the Blackberry, the PDA or the high-tech adjusting tools.  These are all worthy implements for the adjuster, but sometimes low-tech is better.

So, how do you assess YOUR low-tech toolbox?  When you face unpleasant situations in your daily claims handling, do you face them head-on or do you put them off for another day?

What do you eat first — the icing or the cake?

Health Insurer Claim Practices Spotlight Issues with Warped Financial Incentives

September 8, 2009

Today’s Washington Post had a front-page article (“Canceled Policies Spawn Complaints,” 9/8/09, p. A7) on the infrequent but draconian practice of insurance companies pursuing rescission of insurance contracts, in this case health insurance contracts.  The article highlighted a number of people with health coverage who found themselves high and dry after they got sick or injured for allegedly not disclosing the existence of a pre-existing condition to an insurer.

Specifically, the article reported that Health Net, a health insurance company, admitted offering bonuses to employees for finding reasons to cancel health insurance policies.  Reportedly, this practice was documented in company documents produced during the discovery process of litigation.

This highlights the perils of creating claims adjusting financial incentives that are tied to denying claims.  Companies must be very careful in crafting adjuster reward systems so that they reflect a balanced scorecard of metrics, not just financial metrics and not just bonuses for denying claims.

As a risk management program to prevent bad faith, how is your company doing?  Do adjusters or claim staff have any base income or contingent/bonus income that is tied to denying claims?

Consider another form of rescission …


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