Members of the claims management team are required to conduct diligent investigations into workers’ compensation matters, investigate the mechanism of injury, and address issues of compensability. This is a task that requires them to determine if the information they receive fits the type of injury claimed. This includes not only injuries involving a specific incident but also claims that culminated over a period of time. Failure to properly accomplish this task can result in protracted management of a claim and added costs to any workers’ compensation program.
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The Anatomy of a Work Comp Injury
There are essentially two types of injuries employees sustain in the workplace. Each type of injury is unique in how they occur and the evidence one examines when deciding matters of primary liability.
- Specific Incident/Sudden Onset: This type of injury is often easy to identify as it encompasses a specific injury that is easy to identify and occurs at a specific moment in time. These injuries include slip/falls, striking an object, an immediate onset of pain, or a fracture of a bone/joint dislocation.
- Workplace Exposure/Repetitive Trauma: This is often more difficult to identify as to when the “injury” occurs as it primarily happens over a period of time. Common examples include the inhalation of dust, irritants or other substances that result in an injury/respiratory condition. In other instances, problems occur over a period of time that results in the degeneration of joints and discs. Questions as to the “date of injury” are often subject to contentious litigation as each jurisdiction defines when these injuries culminate. Examples include when the employee started missing time from work, when the employee first received medical treatment, or when the employee reasonably believes they have sustained a work injury.
Regardless of the type of injury, a complete investigation is required. Only deny claims in good faith.
Investigating the Mechanism of Injury
It is important for members of the claims management team to investigate and determine if the mechanism of injury (how it occurred) matches the claimed injury. It is also essential to analyze where the work activity is attributed to the work injury, or if the work condition was aggregated and/or accelerated due to work activity. Additional issues to consider include:
- Did an injury occur as a result of the work activities?
- Was the employee performing work activity consistent with the claimed injury?
- If there was, in fact, a work injury, what body parts are actually involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit
- How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?
- If not a specific incident-type injury, when did the injury culminate?
Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.
Making Informed Decisions Regarding Primary Liability
It may be difficult for a member of the claims management team to make a legally defensible position when it comes to primary liability. This can be due to a number of factors beyond their control. If that is the case, utilize the service of a peer review physician or medical advisor to obtain further insight on an action plan for the claim.
Members of the claims management team are charged with a variety of tasks. Chief among them includes collecting applicable evidence and making reasoned decisions based upon the facts of the case and the law. This also involves seeking information on the mechanism of injury and determining if the claimed injury fits.
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 .
Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.