Given recent economic turmoil, many are having a hard time meeting financial obligations. This especially rings true for injured workers, who already have a strike against them — they are receiving workers compensation wage loss benefits at 66 percent to 80 percent of their previous income, and they are injured.
The situation worsens when an injured worker faces situations such as elimination of their job, permanent physical restrictions, or a long recovery after a major surgery. These factors mean pending workers compensation claims are being held open much longer, inflating claims counts for adjusters across the board.
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Below, are five situations that contribute to delays in closing workers compensation files:
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Claimants trying to milk the system.
In the minds of most injured workers, having some money coming in is better than having no money coming in. The injured worker may not have a job to return to or may fear termination because of an on-the-job injury, so they maximize the symptoms of their injury; this is called malingering.
Whatever the reason, a current trend involves injured workers stretching claims out as long as possible. Some purposefully take longer to recover by doctor hopping, trying non-conventional forms of treatment, and exaggerating pain complaints. The length of time out of work must be proportionate to the degree of disability.
Most physicians will catch this and mention something in medical records, which should alert the adjuster to set an independent medical evaluation (IME) or to do some surveillance on the file. Using the MDGuidelines is also helpful; since that offers a range of times a worker should be approaching maximum medical improvement (MMI). If the worker is not back to work within the guidelines, it is time for an IME. Be proactive on the claim or the months will continue to go by and the claimant will achieve their goal.
2. Injured workers have no job to return to for light duty, let alone full duty:
As mentioned above, a common scenario for an extended compensation claim is when the position the worker was in is eliminated, or when the employer does not have a transitional duty program. Since the job market is tight, some injured workers let their accepted workers compensation claim go on as long as possible.
Employers should alert adjusters before job cutbacks so they can discuss strategy on who will be affected. The adjuster can form an action plan to get the claimant back to full duty without letting him or her slip through the cracks.
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Claimants choose to litigate because they have no other choice and nothing to lose:
When claims are denied, workers may think they have nothing to lose by filing for a hearing or seeking counsel. This causes the claim to be open for several months or years while the litigation ensues and parties work toward an eventual settlement. The wheels of the legal system often move slowly, and this contributes to the number of open claims out there. If you take a slow-moving legal system and overload it with everyone filing for a WC claim hearing, you get a backlog of claims and the system barely moves. Stay in touch with counsel to make sure he or she is trying to settle the claim and move negotiations forward. The very best way to avoid litigation is to communicate with the employees. Have an employee brochure, a written transitional duty policy, have employee’s acknowledge receipt of the policy, have a brochure for your network physicians, and most importantly have an Injury Treatment Medical Information Form, a/k/a Work Ability Form. THIS gathers information from the injured employee’s doctor at the first medical visit. Employees contact attorneys because they can’t get information from their employers about their claims or their medical bills are not paid.
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Claimants have severe injuries:
Due to company cutbacks as mentioned above, one worker may be doing the work of three. This leads to employers trying to do more with less. Injuries are bound to happen, especially in more heavy-duty, manual-labor positions. Employees working longer hours and doing more strenuous activity are leading toward a musculoskeletal injury and a probable surgery, if not worse.
These workers may be reluctant to report an injury for fear of losing their job. So they try to work thorough the pain, until the injury gets so bad it needs immediate attention. Workers need to know to promptly report injuries no matter what the circumstance, so they can be treated before it gets worse. Workers with wrist pain wait until they have full-blown carpal tunnel before reporting the pain; whereas if it had been reported sooner, full recovery would have been more rapid and less traumatic; waiting is prevalent when pay is conditioned on production-based pay.
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Some injured employees wait for the Centers for Medicare and Medicaid Services (CMS) to approve the Medicare Set-Aside (MSA):
The dreaded MSA. If an injured worker is eligible for Medicare and the case is in litigation or parties want to settle, in order to settle the claim, an MSA is necessary. This will pay the employee what Medicare would have paid for the continued treatment of the injury. The employee then pays for future treatment from this account. He or she then files paperwork with CMS that tracks the claimant’s continued medical treatment long after the workers compensation carrier settles.
Getting CMS to approve an MSA can take from eight months to two years as there are numerous payment issues to be ironed out. Carriers and CMS employees are adjusting to this new system and, so far, it has not been a smooth transition, according to Gould and Lamb, experts in MSA issues. An adjuster or counsel can further explain how this works in individual jurisdictions.
In summary, workers compensation claim closure rates have slowed nationwide with multiple forces to blame. But, with a good action plan, some persistence, and a bit of patience, these issues can be resolved and the file can eventually be closed for good.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: [email protected].
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My husband was injured at work a month ago, doctor appointments finally MRI he has a torn rotator cuff that will need surgery. Worker’s comp is still processing paperwork to find a doctor to do the surgery, once that is done it will be another doctor appointment paperwork then surgery then paperwork but I bet it will be a shorter span of recovery time to get back on the job than it was to get the problem fixed. He is still trying to work and is in constant pain, IF Worker’s comp can not get paperwork processed then perhaps they need to hire extra workers, they get paid premiums monthly where is that money going while the working person is in pain. Let their CEO get injured and I bet his claim will be processed in one day’s time completely. We were told if he went to his own doctor we would be responsible for ALL the bill.
I had a fall a work and hutted my knee ankle and back. Dr has request pt it going on 7 weeks. And workers comp. Has not done anything. I’m very upset. I grind my teeth a night. I do not know what to do.
I don’t know that what you say is true. I think the problem is mainly with the process. My wife is a School Teacher and was injured on the job. The L&I workers comp claim process is totally rediculous. She has had multiple injuries on the job that started 7 years ago and the latest one has aggravated the previous injuries so much that it has left her crippled to the point that she cannot walk up our driveway anymore, let alone work. She is going stir crazy and is on a huge pile of pills to manage her pain.
The process seems to be all around getting paperwork done to get approvals to do anything. It’s a playbook and there are no ways around that playbook. We are going on 3 months now and we are still trying to get a diagnosis for her issues. She has been to many, many, many doctors appointments. The doctors see that there is a problem, and want to help, but cannot do anything until paperwork is completed so that we can do MRI’s to see whats wrong. This consists of IME’s for each issue and waiting for that to get approved… its just crazy. All that we hear from everyone is, “We are waiting for approval”. In other words, we are waiting on paperwork. We are tired of waiting on paperwork, she is having a horrible quality of life, when do we finally start to do ANYTHING! We have not had any treatment other than drugs for pain and PT, which one of her doctors halted until we know what is wrong since the PT is appearing to cause more pain and disabling her more.
We have had one MRI that shows she has a 13mm bulging / ruptured disc between L4 and L5. OK so we have a diagnosis for her left side new symptoms… but her right side hip symptoms are not explained yet so we are waiting on an approval to do an MRI on that… Expectation is 3-4 weeks to get an approval. The doctors have requested to do it, and we have gotten an IME finally for that, and now we wait for that paperwork to go through. The problem with this is that we have been asking for it for over 3 months, and we are still waiting. Its her main source and highest percentage of pain.