The insurance industry is full of individuals with a lot of experience. In the 30+ years that I have spent in the industry, I have seen a very wide range of experience in dealing with very simple to claims with mind-boggling complexity. Some adjusters performed very well – at an expert level….others not so much. While tenure helped a little, I never found it to be indicative of expertise.
So just what does make someone at expert in claims? A top performer?
Some research on the topic of “expert” suggests that knowledge, skill and experience all play a large role. Wikipedia provides a nice overview. We all generally identify people as experts who can demonstrate they have detailed knowledge of an area and have been at it a long time.
But what difference does this make if an individual can’t translate his or her knowledge into results? We all know or have met claims professionals with seemingly endless technical knowledge. We also know some who struggle to get a claim closed….or worse, who seem to use their knowledge to justify the compromises they make. We all know that knowledge and the skill we assume that goes with it isn’t enough to make someone an expert.
At Casentric, we view expertise as a measurable quantity. Expert levels of knowledge don’t make people experts. Results do. In fact, we start with great results and work our way back to the practices that produced them.
To get an idea of how knowledge translates into results, complete this simple analysis. In your organization, identify the person whom you think consistently gets the best settlements and the person whom you think gets the worst. Pick any venue you like to identify where the claim will be resolved. Now, using the exercise below, write down the amount for which you believe your best person will settle this claim. Next, write down the amount for which the worst will settle this claim. To get the clearest picture, complete this exercise with a few adjusters from your team. Have them independently determine a range, then compare the results.
Exercise:
A 32 year old male is claims a neck and back strain and sprain. His injury and treatment are described as follows:
Initial complaints of pain at 6-7 dropping to less than 3 by end of treatment. Restriction on activities of daily living for 1 week. No time lost from work.
Emergency Room visit or visit to medical facility within 1-2 days of accident. 6-8 Weeks physical therapy. Treatment delivered twice per week. Brief medication for pain relief in Acute Phase.
Range of motion for neck and back restricted to 80% of typical range. Improvement seen at 2-3 weeks with steady progress. Minimal or no restrictions or impairment at end of treatment.
Clinical tests for neurological involvement negative.
No Surgery or recommendation of surgery. No gaps or interruptions in treatment.
Treatment Cost:
Submitted Emergency Room Bill: $4,500
Submitted Physical Therapy Bill: $6,500
Submitted Orthopedic E&M Bill: $900
How much different do you think the settlement of your best performer will be when compared to your worst performer? To take an expert’s approach, think about it this way….By how much would they reduce each medical bill? What would they evaluate pain and suffering at and what information would they use to establish that value?
To give you some background, here’s what we find the advantage of an expert to be:
– Experts settle medical bills at 60% or less of submitted amounts. Non-experts struggle to get below 90%.
– Experts pay as little as half the amount for pain and suffering that non-experts pay.
At Casentric, we focus on expertise in resolving injury claims – developing it, managing it, measuring it, using it to build strong cases that translate into effective settlements. Here is what we know experts do:
They use more arguments and support them with EVIDENCE. Experts don’t call treatment “excessive” or “unnecessary” without indicating why by pointing directly to medical evidence. On average expert adjusters use about 1.5 to 2 times the number of arguments and they use a broader set of evidence. This means more use of SOAP notes, medical reports, medical guidelines, etc.
They negotiate by component to gain incremental agreement. They know that exchanging numbers and opinions does not reflect incremental agreement. It reflects concessions….and leaves ambiguous what has been agreed to. Experts know what they are agreeing to and why.
They present an affirmative case when making an offer. For the case above, they wouldn't start out by critiquing it. They would define it. "This is a case of a strain/sprain injury which was a nuisance, but didn't impact the claimant's day-to-day activity. The claimant received 4 weeks of justified treatment with a reasonable cost of $2,500 and an ER visit that has a cost of $1,100...."
They question demands. Rather than attacking demands as unrealistic, they simply ask...."how are you coming up with that number?" They don't stop there, once that question is answered, they drill in deeper and deeper. In other words, they turn the tables.
They are patient. Experts don't rush the negotiation. In fact, they draw it out spending the time to make sure they understand the plaintiff's case. They use the time to make facts and evidence the basis for the discussion.
The point is this….knowledge alone does not make someone an expert. In fact having knowledge is only the first step in several steps required to be an expert. It is true that experts are more knowledgeable. However, they don’t use this knowledge to demonstrate technical prowess. Experts are interested in using their knowledge to build better cases and negotiate better results. What’s more, their approach can be documented and used to train others.