I had lunch with a nurse case manager not too long ago and we were discussing misdiagnosed conditions. She mentioned to me a case she had recently, where a worker struck his head on the frame of his hi-lo he was driving. He was off work a few days, diagnosed with a head contusion, and sent back to work. He later had some difficulty with dizziness and headaches, to which doctors advised it was probably a mild concussion.
Why Would The Adjuster Fight Nurse Case Manager Opinion And Resist A Second Opinion?
Since the nurse had spent more time with the patient than the doctors, she wanted to get a second opinion. The worker’s wife mentioned to her some issues with attention and minor memory issues. These issues were not brought up to the doctor by the patient himself. To her dismay, she had to fight the adjuster a little bit (Adjuster mistake #1) but in the end she sent the worker to an occupational doctor that had some sort of additional qualification in traumatic brain injuries. It turned out after some testing that the diagnosis should have been a mild traumatic brain injury. After some rest, medication changes, and some modified treatment methods the worker was doing a lot better and showing signs of improvement.
On the way home I was thinking about why the adjuster would resist getting anther opinion in a head injury case such as this. Especially with blows to the head, an adjuster should never limit themselves in getting opinions–especially if directed by their own nurse case manager.
Chances are the adjuster did not want to face the fact that this injury may have been more complicated or more severe than they first thought. Chances are also that this adjuster may not have wanted to escalate this claim into being one that required a reserve increase or one that drew more attention to it from their managerial staff at the carrier. Since the adjuster would probably be in trouble for not reserving the claim properly from the get-go and for not keeping an open mind to other complications, you would think it would be worse to just pretend the problem does not exist.
Early Intervention Is Key to Any Head/Brain Injury
In any type of brain injury, early intervention and treatment is key to a successful treatment plan. The worst thing to do is ignore the warnings signs. These could be persistent headaches, dizziness, memory issues, speed of task completions, and so on.
Watch for the Method of Injury
A tip to watch for while evaluating a claim for brain injury involvement is the method of injury itself. Any case where the head was struck by an object should be a red flag, but my conversation with this nurse shows that for some adjusters a head injury can go under the radar.
Watch for Injured Worker Complaints
Even if some diagnostic testing results were to be normal, I would put more emphasis on the injured worker’s complaints themselves. Sure, you have to consider malingering to some extent, but when you weigh the severity of the accident itself against what incentive the worker has for secondary gain, this is hat the job of the adjuster entails.
Don’t Be Afraid To Ask for A Second Opinion
Don’t be afraid to reach out for second opinions early in a claim. Neuropsychological testing, diagnostic testing, and other physician opinions are all going to help you put the pieces of the puzzle together.
Talk With Spouse of Partner of Injured Worker
Another important resource often untapped is conversations with the family or significant other of the worker. They are going to tell if the worker is behaving differently after the injury when compared to their normal behavior before the accident. There is no rule that says you cannot talk to the wife or partner of the injured worker. If you as the adjuster can reach out to them, and even set up an appointment to talk with the worker along with their family early on in the claim, it can provide valuable insight as to any injury side effects
Make Sure Injured Worker Reporting All Symptoms To Their Doctor
Another thing to watch for is the injured party not telling the doctor all of the symptoms he or she has. Sometimes people just want to get back to work, and they could downplay their symptoms in order to just get back to work. They are not helping themselves by doing this, and they could be putting other workers in danger should they have a traumatic brain injury that is undiagnosed and untreated.
So take your time and do a thorough investigation early on with any head injury claims. Look for the warning signs, and do not be afraid to get additional recommendations and a handful of diagnostic tests. Most importantly, listen to the concerns of your nurse case manager. You could stop a potential bad claim from happening in the first place.
Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: [email protected].
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