Employers are often surprised to learn what they thought was a medical-only claim has become a lost-time claim. This unpleasant surprise can often be avoided by basic due diligence on the part of the employer. The following are reasons medical-only claims become lost-time claims and what the employer can do to prevent such an occurrence.
Inappropriate Initial Medical Care
When an employee is allowed to select the medical provider, he or she usually does not select the best provider for their on-the-job injury. The employee’s personal family physician may be great at caring for the employee’s kids when they have the flu, however, the family doctor will often not understand the ramifications of taking the employee off work “for a few days.” If a family doctor tells the employee to “rest at home” until the muscle strain is better or the laceration heals, no one is thinking about the employer-offered modified or light-duty program.In states where the employer has the choice of selecting the medical provider, going to the wrong type of medical provider should never happen. The employer should have an approved medical provider(s) list posted where all employee will know who to go to in the case of an injury. Also, the employer’s work comp coordinator should verify the employee goes to an approved medical provider. In states where the employee can select their own medical provider, the employer should still post a list of recommended medical providers who the employer has pre-screened to verify the medical providers specialize in workers’ compensation and understand the modified duty program.
Tough It Out
The quick way to make a mild injury more severe is to allow the injured employee to “tough it out.” The macho guy, more concerned about what his co-workers will think, may keep on working. The strained muscle that is already weakened from the initial on-the-job injury gets used and becomes injured to a much greater degree. What would have been two weeks of light duty with the appropriate initial medical care becomes two months of temporary total disability.
Any time an employee reports an injury with the description, “But it is nothing.” the employee should be sent to the employer’s required medical provider (in the states where the employer selects the medical provider) or to the recommended medical provider (in the states where the employee can select the medical provider). Often the employee is concerned about paying for the medical care and about losing time from work. The employer should tell the employee that the company will pay for the doctor visit and that he or she you will not get docked for time at the doctor’s office. Simple communication, which also shows the employer is concerned about the employee’s welfare, will keep the “tough it out” from becoming the indemnity claim.
If there is no post-injury process to keep an employee in the loop — such as making sure his or her medical care is coordinated — things can go wrong that keep the employee out of work. A triage nurse will do an initial assessment of the injury by phone using medical protocol, and will provide the names of doctors to the employee and advise the employee of the name, location, and directions to the medical provider. Triage will determine whether emergency care is necessary, whether a clinic visit in 2 days is OK, or whether the employee needs to ice the injury and rest the swollen ankle. In short, the employee receives the right kind of care at the right time. In states where panels are provided, the names of all doctors on the panel are sent to injured employees immediately. Use triage nurses that are URAC certified.
The fastest way for both the employer and the claims office to turn a medical-only claim into a lost time claim is to ignore the medical-only claim, thinking it is insignificant. If the adjuster and the employer do not tie down the nature and extent of the injury early on, it often invites trouble. The employee who strains his back and is just “sent to the doctor” with no follow up, can take advantage of the situation. The employee who has had a neck problem for years, and the doctor is already treating back strain, is given the opportunity to advise the doctor that the neck was hurt in the accident as well, resulting in enough issues that the doctor takes the employee off work, with the work comp insurer paying for the medical care and lost time due to a pre-existing injury. If many claims are converting to lost time claims, evaluate the post injury response carefully.
Note: Make sure the employee has a Work Ability Form to take to the doctor on the FIRST MEDICAL VISIT. This is the #1 reason medical claims convert to lost time claims — employers do not have the right forms in the hands of the employee and doctor at the right time. Without the Work Ability Form to provide medical restrictions for transitional duty, the employee must return to the doctor, waiting another week or so, thus turning the medical only claim into a lost time claim.
Questionable to Begin With
When the employee decides ahead of time to have an “accident” that will be unwitnessed and consist of subjective complaints of strain and pain, it is up to the employer and the adjuster to cut off the fraudulent claim before it can be built up to a lost-time claim. Any time the employer thinks to herself, “That is unusual,” the adjuster should be immediately notified to be sure to do an in-depth investigation. The most effective thing an employer can do to stop potential fraudulent claim is to contact the doctor’s office immediately — even before the employee arrives for the initial visit — to advise the doctor’s office of the modified-duty program awaiting the employee’s speedy return. And, it also helps the employee to know that all work comp fraud is prosecuted. Post anti-fraud posters in the workplace.
Something for Nothing
Similar to the “questionable- to-begin-with” claims are claims in which the employee has a valid injury (for instance, a trip and fall that results in bruises) but the employee figures now is the time to “Take a vacation on work comp.” When an employee thinks, “Let me see what I can get out of this,” failure to control medical and to offer light duty will result in a minor injury becoming a lost-time claim. The employer should have an employee brochure in the workplace advising of obligations when an injury occurs letting employees know transitional duty is available and expected of all injured employees.
There are times when the medical severity of an injury is greater than originally suspected. Sometimes conservative medical care is not enough. An MRI may reveal what was thought to be a strained shoulder is actually a torn rotator cuff, or the strained back is a herniated disc. In these situations there will be some justifiable lost time. It can still be minimized however by having the appropriate transitional duty program in place and working with medical providers to ensure prompt, quality medical care.
By being involved in all your workers compensation claims, not just the severe ones, the employer can prevent many medical only claims from turning in to indemnity claims. We always recommend the employer has a work comp management program as a part of the overall risk management program in place to control situations like this.
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 is 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 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@example.com.
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