Two Key Tactics to Avoid “Creeping Catastrophic” Workers’ Comp Claims

We know that aside from traumatic injuries, the vast majority of workplace injuries heal as expected. However, we also know that roughly 20 percent of seemingly minor injuries turn into major problems, leading to complex medical treatments, long-term recoveries, and major expenses. These claims are often referred to as ‘Creeping Catastrophic’ Claims. The question is why do these types of claims occur?

There is no single answer since every injured worker is different. But we know that biological, psychological and social factors — or a combination of all three, are often to blame. Uncovering and intervening on those issues early in the claim cycle can pay dividends in the long run. Using the right approach at the right time can keep the claim on track for a favorable outcome.

Biological, Psychological & Social Factors

Factors that may have nothing to do with the injury itself may impede the recovery process and be a significant cause of Creeping Catastrophic claims. Biological factors, such as the person’s genetics, age or gender, may impact recovery. There may be mental or emotional health issues, beliefs, expectations or other psychological elements that have a bearing on the healing process. Social issues, such as financial strain, support systems and relationships can easily derail a claim.

Let’s say an injured worker takes a bus to and from work; however, no bus is available to him to the location of, or at the appropriate times for medical appointments. An injured worker in this situation won’t be able to get the treatment he needs and, therefore, cannot be expected to have a smooth recovery. Having this knowledge at the beginning of a claim allows claims managers and others to work with the injured worker and figure out some available options — rather than finding out this information weeks or months into the claim.

Another injured worker may have cultural issues that render her unable to work with particular medical providers. Again, knowing this early on can allow stakeholders to direct care or steer the worker to someone more appropriate, saving time, money and unnecessary suffering.

There are also injured workers who must care for an elderly parent, which may prevent them from going to physicians at certain times or strictly adhering to their medical regimens.

These issues are not the responsibility of the payer, yet ignoring them or failing to recognize them can turn a minor injury into a complicated nightmare. It is incumbent upon payers to do everything possible to find out and address any issues that could harm recovery.

Trust and Engagement

Injured workers are typically scared, confused, and possibly angry. Since they probably have no first-hand knowledge of the workers’ compensation process, they may feel out of control and powerless over the situation. Add to that the fact they are likely in pain, and it’s no wonder they may be less than forthcoming with their life issues that may impact a claim.

On the other hand, an injured employee who trusts the payer — or a representative of the payer, understands the process and feels that he is at the center of his recovery is much more likely to discuss non-injury factors that could significantly affect a claim. A biopsychosocial approach to managing claims can truly engage the injured worker, so he feels comfortable sharing certain aspects of his life outside of work or his injury.

Key to the approach is:

• Timing
• Genuine Communication

1) Timing. The first available opportunity for someone to speak with the injured worker is the right time, whether that is within the first two days, the first day, or the first hour of the injury. That is when the injured worker is trying to make sense of what has happened to her and what she can expect — before she has had days or longer to get ‘advice’ from family members, well-meaning friends or attorneys on TV. It is when she is most likely to listen to and if done correctly, trust the person speaking with her.

That first conversation with the injured worker should not be viewed as an unemotional session where the claims manager is firing questions, but instead should be an empathetic, interactive dialogue. The main focus should be explaining the process and the injured worker’s options, listening to and addressing her concerns and fears, and expressing genuine care and concern — and emphasizing that the goal is to help her heal and return to her job. It is the first step in building a relationship with the injured worker, not just a one-off, quick chat.

2) Genuine Communication. Often the best person to initiate this first conversation is the nurse case manager. He may have insight into the injured worker’s medical issues that can be discussed.

His approach should be easy, to try and establish trust with the injured worker. In discussing the workers’ compensation process, he may set expectations; for example, saying he expects the injured worker to call him after her medical visits. It lets her know that he is going to be with her for the long haul.

The initial and subsequent conversations should be just that — conversations. In addition to discussing the injury and the process the injured worker will go through, the discussion should also center around other things important to the person. Is there a spouse and/or children who may be experiencing some of the same fears and concerns as the injured worker? What are some outside activities that may be affected by the injury?

Learning about the injured worker’s life outside of work can also help in the recovery process. Once the nurse and/or claims manager has a better understanding of what is important to the injured worker, that information can be used as motivation to help with her recovery. For example, if she plays in a golf league once a week, the nurse or claims manager can share that information with other stakeholders and incorporated into the treatment regimen.

Conclusion

Injured workers are far too often left feeling out of the loop in their own recoveries. Including and engaging them early on and using a holistic approach empowers and motivates them to have a positive experience, and avoid the life-altering impact of a creeping catastrophic claim.

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.

Contact: [email protected].

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