Why Little Work Comp Claims Become Big Claims

Few things are as stressful to the risk manager as learning that a small medical only workers’ claim has morphed into a lost time claim. Often it seems that there is no warning that the small claim is about to spin out of control. Careful analysis of the medical only claims that transform into new lost time claims will frequently provide insight as to why they changed.

Failure to Obtain Medical Care

An injured employee who is concerned about losing time from work, or who does not know the employer pays for the medical care of on-the-job injuries, may elect to not go to the doctor. When the injured employee reports the injury to the job supervisor but then declines medical care, many employers will make an “incident only” record. This is the easy way out of handling a workers’ compensation claim, but this approach often backfires.

The employer should always encourage the employee to seek medical treatment “to be on the safe side”. Often with muscle strains, the injured worker keeps using the injured body part. The injured body part is susceptible to further injury and the minor injury becomes aggregated from further use resulting in a much more severe injury. A minor strain that could have been doctored by the local walk-in medical clinic and resulted in a week of light duty instead becomes a complicated injury with time off work and extra medical appointments.

Improper Medical Care

When employees select their own medical provider, they usually do not know how to select the best doctor for their industrial injury. The family doctor is fine for treatment of routine sicknesses, but normally has no experience or limited experience dealing with work related injuries. The family doctor will often tell the employee to “stay home” until he/she is well, and never think about the employer having a light duty work program available.

In approximately half of the states where the employer selects the medical provider, the employee should never go to any medical provider that is not on the employer’s posted panel of required medical providers. In the other states where the employee can select the medical provider, the employer should post a list of recommended physicians who are all experienced in occupational injury treatment. In many cases the employee will consult the posted list of recommended doctors.

Lack of Medical Triage

The triage nurse is responsible for recommending the appropriate level of medical care to the employee. When an employer (or insurer) does not have a triage nurse, the employer is left to determine the care, which nearly always defaults to the emergency room. The employer also needs to explain the return-to-work program to the employee. It is up to the injured employee to describe his regular work duties to the medical provider, which more often than not will result in the medical provider keeping the employee off work.

Possible Fraud

When an injury is reported that just doesn’t seem right, even if the injury is reported to be minor, the employer should act without delay to prevent the injury claim from becoming a lost time claim. The employer should contact the medical provider immediately to explain the modified duty program, and reassure the medical provider that the employer will accommodate any necessary work restrictions the medical provider may feel are necessary (out of an abundance of caution). Frequently with a fraudulent claim, when the employee realizes that he/she is not going to get paid time off, the desire to pursue the fraudulent claim is lost.

Failure to Establish the Extent of the Injury

A mistake frequently made by both adjusters and employers is the failure to tie-down the exact nature and extent of the injury. For example, the injured employee hurts his shoulder lifting an object. If the employee has not been contacted by the employer, adjuster or a triage nurse, the employee is able to ask the doctor to treat his neck which has bothered him for years. While the shoulder strain would have landed the injured employee on light duty work, the shoulder strain plus the neck is enough for the doctor to justify keeping the employee off work. A detailed interview of the employee by the supervisor or the workers’ compensation coordinator, including the question “was there any injury to any other part of your body?” will head off the inclination to expand the claim to additional body parts.

We recommend employers to be involved in all of their workers’ compensation claims. By being involved in all claims, medical only claims will remain medical only claims and not be expanded to lost time claims.

 

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 the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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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.