Who Is Ultimately Responsible For Work Comp Claim Outcomes?

A question I get asked a lot is “Who is really responsible for workers comp? Is it the employer, the adjuster, the nurse, the doctor, the attorney, the injured worker…. who is the one steering the boat? Who is really in charge?”

That is a great question. When you strip all of the layers away, who really is in charge? Who has the final say and who is really held accountable at the end of the day?

Employer Is Ultimately Responsible & Accountable

The answer is the Employer is ultimately responsible and accountable, but every party has a role and all parties contribute to the outcome of a workers’ comp claim.

In order to put together a successful team, we have to understand the role of each party:

• Employer– initial investigation onsite of accident details, witness statements, completing the injury forms both internal and external, filing the claim promptly, providing light duty, job descriptions, and staying in communication with the injured worker. They must also be in constant communication with their claims adjuster to make sure the case is moving forward to resolution.

• Adjuster- investigation and handling of the claim, communicating with all parties timely and often, assignment of nurse/counsel when appropriate, reserving the file for exposure, setting up IMEs when needed, etc.

• Nurse case manager– their role is communicating with the injured worker, medical provider, and adjuster on case details from the medical point of view. Also the NCM should be pointing out ODG guidelines, necessity of treatment/diagnostics, opinion of local treating physicians/rehab facilities, as well as making sure the doctor addresses specific questions in transcription especially when regarding return to work light duty/full duty. They bridge the gap between the adjuster, employer, injured worker, and doctor.

• Doctor– Providing reasonable and necessary medical care, work restrictions, directing rehab and completion of diagnostic tests when needed. The doctor should also be communicating with the NCM/adjuster/employer as directed. Their office must also provide timely medical documentation that is complete and pertinent to the case when asked certain questions from any party. Physicians should be rendering treatment based on objective medical evidence and not subjective complaints from the injured party.

• Attorney- The attorney should provide legal opinion with case law support within the jurisdiction. They should also be attending any legal conferences/meetings in regards to the case, and communicating with the adjuster/employer as directed as well as overall case exposure analysis and settlement ranges when applicable.
  

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• Injured worker- The injured worker’s job is to heal and recover so they can return to full duty. They also should be communicating with their employer/adjuster on their medical care, rehab, the effectiveness and the care, and if their concerns are being listened to from all parties.

This is not a comprehensive list of responsibility, but it does cover the main points of each role. The important thing to remember is that if you remove one of the parties, it causes the overall process to break down. Everyone has a role, a responsibility, and a duty to communicate, listen, and to keep moving the case forward.

Cases stall out when one of the parties has a breakdown in communication. This could be from anyone, at any time, but most cases will fall apart when someone is not completing their tasks; whether the doctor, adjuster, attorney, or injured worker. When this happens, it is the employers responsibility to hold this party accountable.

If you see cases that are breaking apart or stalling out, reexamine the communication involved. Be sure that all parties are doing their jobs, and being held accountable when gaps in communication appear.

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].

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