Professionalism, Options and Fault

Three themes arose in conversations I had with various professionals at the DWC Educational Conference in Oakland this past Monday and Tuesday: there is a declination in the professional claim adjuster ranks, an opt-out option would win with large California employers and people keep trying to infuse fault into a no-fault system.

The declination in the professional adjuster ranks took two characteristics: a less educated, experienced work force on the front lines of claims management, and an erosion of new blood coming into the job.

Nearly every single person in which this topic of discussion came up opined that education of professional claims adjusters, despite Insurance Code mandates requiring ongoing training, failed to maintain a good level of proficiency in the claims ranks.

If you're a claim adjuster reading this, you may agree or disagree - but at least the folks I talked to were concerned that the requirements to become a claims adjuster have laxed while at the same time the actual education adjusters get ends up effectively stopping once a case load has been assigned.

With respect to case loads, most were of the opinion that the reason adjusters don't get the education needed to attain and maintain proficiency was because there simply isn't sufficient time.

Case loads have increased because so much of what an adjuster used to do has been outsourced: utilization review, bill review, medical authorization, etc. Because of the rote outsourcing of claim examination elements the claims adjuster's job has become more of technician-type of work rather than one where decision-making skills are paramount. As a consequence such decision-making skills have deteriorated on a broad basis.

Folks were also concerned that us baby-boomers who have been adjusting claims for the past 30 years are retiring or otherwise leaving the system, and that there was no concerted effort by the industry to recruit and train new adjusters, which of course puts pressure on existing case loads.

There were several people I talked to at the upper ranks of large multi-state companies with experience in Texas non-subscription systems, and they are anxiously awaiting the Oklahoma legislature to pass that state's proposed opt-out system, SB 1062, and thereafter in Tennessee.

At least in the eyes of these risk management professionals, their Texas opt-out systems are less expensive and much more efficient than workers' compensation, producing superior performance resulting in better care for their employees.

There are some, of course that are going to debate that, but the prospect that these employers could take workers' compensation into a private setting and do it better than anything a state legislature could envision was very, very appealing to them. They had no problem meeting minimum standards - to these folks, the freedom to design a plan that fit within their corporate culture to achieve the results they desired was most compelling.

It is all about control over the system and its consequences.

The last topic of discussion was the constant attempt to infuse fault into a no-fault system.

This just may be a human thing - we need to blame someone for something that we feel is inequitable regardless of what the law says.

This is common in divorce litigation - the need to blame the other for the failure of the marriage even though the law says that it is not going to pay attention to fault.

The need to ascribe fault interferes with the decision making process.

We see this in attempts to create legislation - for example the recent attempt in the filing of AB 1309 in California that would eliminate extraterritorial jurisdiction and excise continuous trauma claims in California for some professional sports athletes/employees.

According to the Los Angeles Times, California Assembly Insurance Committee Chairman Henry Perea (D-Fresno), who is the sponsor of AB 1309 said the bill is expected to be a "starting point" for a lively legislative debate over whether claims from out-of-state retired players represent abuse of the California workers' compensation system and wind up hitting all California employers with higher premiums and surcharges that pay for outstanding claims left by failed insurance companies.

Perea is blaming, ascribing fault, to a subset of claimants for a system's overall woes. In my opinion this is an improper analysis for such a dramatic change in the law.

I don't pretend to understand the psychology of blame and fault, but it is a characteristic that we need to keep in check if in fact workers' compensation is to remain a no-fault system.

So there you have it - my education at the DWC 20th Annual Educational Conference. I'm not saying any of this is right, wrong or relevant. It's just what was being talked about.