Causation is one of the most challenging concepts in the claims community. Causes of low back pain, carpal tunnel syndrome, and other soft tissue pain are often a matter of conjecture on the part of treating physicians, leaving claims managers scratching their heads.
But that doesn’t mean you have to blindly accept the doctor’s diagnosis on a claim with obvious red flags. Partnering with the right experts can better ensure payers don’t end up footing the bill for a non-work related injury.
The back is the most common body part facing the claims community, and causality is the challenge. That statement during a recent webinar speaks to an all too familiar problem in the workers’ compensation system: determining the cause of an injury where there is often no clear-cut answer.
Unfortunately, many treating physicians are not focused on causation and instead seek only to help their patients. They take the word of the patient that the pain is work-related.
Many payers are apt to simply accept the treating physician’s determination, figuring da challenge of the doctor’s opinion will likely end up costing more money in the end. However, the problem is often not limited to one or two such cases. “Contagious syndrome,” a term coined by attorney Stuart Colburn, refers to the phenomenon where other workers see a colleague receiving benefits for soft tissue injuries and claim their own.
A 35-year old worker files a claim for a lumbar strain he says he sustained at work. Additional facts are; he is overweight, has a new baby at home, and has expressed an interest in becoming a dispatcher on light duty.
In another example, an older woman claims carpal tunnel syndrome in her right wrist, has surgery and returns to work. Six months later, she says her wrist never fully healed and files a claim for CTS on her left wrist. She says both were caused by her repetitive motions at work. Her supervisor has alluded to potential psychosocial factors.
In both cases, comorbid factors are clearly evident. In addition to being overweight, the male with low back pain is likely losing sleep due to the new baby (an evidence-based factor for low back pain) and has indicated he would like to be transferred to a less-intensive job on light duty. The other worker has at least two comorbid factors that are indicative of CTS: being female and older.
- Know the risk factors. Evidence-based medicine identifies clear risk factors for developing soft tissue injuries, both work-related and non-occupational. For example, CTS may be work-related if there is a combination of force and either repetitive motions or awkward posturing. But repetitive motion on its own is not an evidence-based cause of CTS. There are few work-related causes of low back pain. Job dissatisfaction is perhaps the biggest.
- ID appropriate physicians. Where possible, you want to work with physicians who understand the issues surrounding occupational injuries, such as the importance of determining causation and return-to-work. In rural areas where there are few or no occupational physicians available, payers need to educate physicians on workers’ compensation-related issues
- Provide job insights. Physicians faced with a patient in pain want to help the person and tend to believe what they are told. The worker who says he injured his back because he is routinely lifting heavy objects and/or is in awkward positions may be misrepresenting his actual job duties. Payers can clarify job duties in several ways:
- Invite the physician to the worksite to see what the job entails.
- Videotape someone doing the job so the physician can see the actual tasks involved.
- Provide a thorough, detailed job description so the doctor understands what the worker does on a day-to-day basis.
Review the history. The claims adjuster should look at the worker’s
- Previous work history; i.e., what he did before working at your company. This may reveal activities consistent with his current complaint.
- Check medical records. There could be prior injuries in the same or nearby body locations, indicating the injury is not new. This may also show comorbid conditions that could be factors.
- Determine employment start date. See if the worker is a long-time employee or a new hire, which may be a red flag for a preexisting condition.
- Approach the physician. If your reviews uncover several red flags, your claims adjuster may be able to convince the physician to take a closer look.
- Use peer review. The insurance carrier or third party administrator who is managing the claim can request a peer review. An independent medical reviewer can look at the records, test results, etc., and may have a different opinion from the treating doctor. The peer reviewer probably stands a better chance of persuading the treating physician to consider revising his initial determination, since it is a physician to physician discussion.
Ideally, you should have established relationships with peer review physicians. If not, the insurance carrier or third-party administrator may have some available.
Identifying causation for a soft tissue injury is often as much of an art as a science. But following evidence-based medicine and working closely with treating physicians can get you that much closer to the true cause.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .
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