Some things were much simpler back in the day, like determining whether an employee’s injury or illness should be compensated through workers’ comp. Workers tended to stay with the same employer throughout their careers, creating a solid trust level on both sides. Employees were also more inclined to retire earlier, before the onset of age-related and comorbid conditions.
But things are more complicated now, and proving causation can be a tricky business. You want to ensure that injured workers who sustain work-related injuries at your company are duly compensated, but you certainly don’t want to pay for injuries that did not result from your employment. While determining causation is not an exact science, there are some tools you can use to ensure you pay only for those injuries truly related to your workplace.
The best place to start is at the beginning, as soon as you get word of an injury or illness. Work with your team to find out what happened. In addition to speaking with the injured worker, talk to any witnesses. Drill down to the details. Ask lots of questions – of witnesses and others who may have been aware of potential problems in the area in question. Take pictures of the area, since that may shed some light on what was happening at the time. If nothing else, you may at least uncover a festering problem in your workplace that can be corrected to prevent another injury.
Look at the mechanism of injury
The mechanism of injury can reveal valuable details to medical professionals about injuries to the bones, skin, muscles, and organs. Did the person fall from a height? How high? Or, was it a ground-level fall? If it involved a motor vehicle accident, what speeds were involved? Get as many details as possible as soon as possible after the injury is reported.
Understand chronic vs. acute
While the medical nuances are best left to those in the biz, you can at least have a general idea so you can speak the lingo with medical providers, adjusters, and others. The problem with chronic conditions is that they affect just about everyone on the planet in some way, at some time, and often we don’t even know it’s happening to us. Degenerative changes may build up somewhere in the body yet the person has no awareness of it until an awkward movement at work renders him wracked with pain. Of course, he assumes it is work-related. But maybe it’s not.
For example, arthritis is not typically aggravated by soft tissue trauma, so check that out before you agree to pay for a knee replacement in such cases. Researchers have found that low back pain — one of the most common ailments among injured workers — often has a genetic basis rather than a link to occupational activity. A rotator cuff injury may be chronic, especially if it is associated with muscle atrophy; however, such a tear may become larger after acute trauma. And contrary to what many believe, carpal tunnel syndrome does not necessarily result from keyboarding. It behooves you to request and get medical evidence to help identify what your responsibility under workers’ comp is and what is not.
Use quality providers
Seek medical providers who use evidence-based medicine, especially in jurisdictions where you have a say in the physician the injured worker sees; look at their credentials — board certification, etc., and check out their educational backgrounds. Same with other providers and medical facilities — you want to make sure the MRI that’s the basis of your decision on a claim is of high quality and read by a top-notch radiologist.
If you use a medical expert in a challenge to a claim denial, find one that is believable. Ask questions such as how the provider arrived at a certain diagnosis, whether the mechanism of injury was accurately described and applied, and how evidence-based medicine pertains to the case.
Know the law
Causation standards have changed in a number of states in recent years, with many requiring work to be the major contributing cause of injury. However, some injured workers and their attorneys have become more adept at challenging those standards.
There are also legislative proposals in several states that would ensure first responders are compensated for instances of post-traumatic stress following an incident on the job. Still other statutes or proposals would guarantee benefits to firefighters who contract certain cancers. It would be a mistake to assume all states have the same types of allowances for workers’ comp benefits.
Weeding out legitimate claims can be tough, as there is often no black-and-white answer. Being proactive when a claim is first reported and using the right experts can save you headaches, time, and money.
Michael Stack, CEO of Amaxx LLC, is an expert workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employers and ties results to a Critical Metrics Dashboard.
Workers’ Comp Roundup Blog: http://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.