In My First Week as a Claims Adjuster, I Was Approving Surgeries


“In my first week as a claims adjuster, I was approving surgeries.”


So said a prominent corporate risk manager at a conference I recently attended. No experience adjusting claims, no medical training, yet given the power to determine if you could have back surgery, hand reconstruction, repaired knees or elbows, etc. What were they thinking?


I frequently write about utilization review and its many benefits. The ultimate goal of good UR is to ensure that the injured worker gets the proper treatment at the proper time. We have learned that claims which result in the best medical outcome are those which are actually the least expensive. So how do we get there?


First and foremost we must have folks who know what they’re talking about…doctors, nurses, physical therapists, etc. I don’t let an auto mechanic with three days of experience work on my car. Why would I let a newbie be THE decision-maker in whether a surgery is medically necessary, appropriate and timely?


Payors like to save money. And some believe they can save money by approving everything and avoiding the cost of UR. It’s hard to figure how the ensuing bad medicine can produce a healthy result for either the patient or the payor.


Call us. We can do better.


William Faris, JD
Chief Executive Officer

Posted in OMCA, Workers’ Compensation