The Department Comes To The Aid Of California Employers

By Aldon Bolaños

The California Department of Insurance recently released its long-awaited regulations governing the minimal level of competence required of workers’ compensation claims adjusters. This article will touch on an overview of these regulations.

The purpose of these regulations is to ensure a level of adjuster competence in the handling of claims for workers’ compensation. Anyone who has tried to navigate the myriad complexities of California’s workers’ compensation laws knows that the proper administration of benefits to injured workers is something easy to preach and difficult to practice. Tasks as simple as computing disability payments based on wages or as complex as determining what sort of modified work conforms to physician-imposed work restrictions simply cannot be performed properly without adequate training.

Beyond the purpose of promoting competence, these regulations are a powerful tool for employers looking for the best coverage to suit their business. Insurers will be required to file an annual certification stating the number of “certified experienced” adjusters they employ as well as what percentage of the claims adjusting staff is “certified experienced.” Most importantly, policyholders may now request proof of certification for those adjusters handling their claims.

“The purpose of these regulations is to ensure a level of adjuster competence
in the handling of claims for workers’ compensation.”

Under the regulations, a “certified, experienced claims adjuster” will be someone who has undergone 160 total hours of training on all aspects of claims handling. At least 120 of these hours are required to be in a classroom with an experienced instructor. The remaining hours may be “on the desk” training under the supervision of an experienced adjuster. Training topics include knowledge of the policy, the compensability of claims, evaluating and rating disability using the AMA Guides, procedures at the WCAB, reserving, apportionment, use of the ACOEM Guidelines for medical treatment and fraud. Additionally, adjusters will be required to maintain their expertise with periodic refresher courses at the risk of losing their certification.

The Department of Insurance has taken a positive step toward protecting California’s employer community from claims mishandling. It is now up to the insurers to follow suit and provide a level of claims handling competence to workers’ compensation that has been lacking during the years of the crisis. Of central importance will be adjuster understanding and use of the ACOEM Guidelines, which are designed to curb over utilization of medical treatment—the main cost-driver behind large claims for compensation. As with the regulations for Medical Provider Networks, the mantra for California employers should be “control the medicals, and you control the claims.”


 

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