Finding the Claims That Will Blow Up Your Costs—Before They Do

By the time a workers’ compensation claim has been open for six months, the outcome is usually already decided.

Costs are entrenched.
Positions are hardened.
Return-to-work odds have dropped dramatically.

The real opportunity to change the trajectory of a claim happens much earlier—within the first six weeks.

Best-in-class workers’ comp programs understand this. They don’t wait for claims to “declare themselves.” They proactively identify which claims are likely to spiral and intervene while change is still possible.

Why the First Six Weeks Matter

Data consistently shows that a small percentage of claims—often 5–10%—drive 70–90% of total costs. The challenge is that these claims rarely look catastrophic at the beginning.

They start as:

• Shoulder strains

• Knee sprains

• Back pain

• Slip-and-fall injuries

If employers wait for costs to rise before paying attention, they’ve already missed the window where intervention is most effective.

The goal isn’t to predict the future with certainty. The goal is to identify risk early enough to act.

The Goal of Early Identification

High-performing programs aim to:

• Identify 80–90% of high-risk claims

• Do so within the first six weeks

• Apply this process consistently and system-wide

This is not guesswork. It’s a structured combination of observation, participation data, and targeted screening.

Step One: Assume the Fundamentals Are in Place

Early identification only works if basic claim fundamentals are already functioning:

• Prompt injury reporting

• Strong communication with employees

• Active return-to-work programs

• Appropriate medical direction and triage

Without these, too many claims drift unnecessarily, and screening becomes a substitute for fundamentals instead of a supplement to them.

Once those basics are in place, early identification becomes a powerful refinement—not a bandage.

Step Two: Informal Risk Screening (What You Already Know)

The earliest indicators of a high-risk claim are often visible without any formal tools.

Supervisors and claims teams can assess risk informally by observing:

• Attitude toward the injury and employer

• Job satisfaction and engagement

• Honesty and consistency in reporting

• Emotional state and resilience

• Willingness to participate in the process

Employees who are frustrated, disengaged, or already overwhelmed by life stressors are statistically more likely to experience delayed recovery.

This isn’t about judgment. It’s about awareness.

Step Three: Participation Is the Earliest Measurable Red Flag

Among all early indicators, participation in the claims process is one of the most predictive.

Warning signs include:

• Delayed injury reporting

• Missed medical appointments

• Poor communication with adjusters

• Resistance to reasonable care

• Refusal of transitional duty

When employees disengage early, claims are far more likely to escalate. Participation—or lack of it—often tells you more than diagnosis codes ever will.

Step Four: Formal Screening Tools That Actually Work

When informal indicators and participation data suggest elevated risk, formal screening adds clarity.

Two tools stand out for early identification:

1. ReBo (Örebro) Pain Screening Questionnaire

• Takes approximately six minutes

• Predicts long-term disability and failure to return to work

• Identifies low, medium, and high-risk claims

• Proven accuracy approaching 90%

2. PHQ-4 (Patient Health Questionnaire)

• Takes about two minutes

• Screens for anxiety and depression

• Identifies psychological risk factors that delay recovery

Both tools are free, quick to administer, and designed to complement—not replace—clinical care.

When to Trigger Screening

Effective programs don’t screen everyone automatically. They use clear triggers, such as:

• No return to work within two to four weeks

• Recovery outside expected duration guidelines

• Informal risk indicators

• Participation failures

• Predictive analytics flags

This targeted approach ensures resources are focused where they matter most.

Why Early Identification Changes Outcomes

Early identification doesn’t mean labeling a claim as “bad.” It means recognizing that some claims need additional support.

When high-risk claims are identified early:

• Interventions are more effective

• Disability duration decreases

• Costs are dramatically lower

• Employees receive support when they need it most

The difference between a $35,000 claim and a $150,000 claim is often not the injury—it’s timing.

The Takeaway

Creeping catastrophic claims don’t explode overnight. They reveal themselves through patterns—if you know where to look.

The first six weeks are your best chance to change the story.

Organizations that systematically identify high-risk claims early don’t just reduce costs. They prevent routine injuries from becoming life-altering events.

And that’s the definition of a system that works.

Michael Stack, CEO of Amaxx LLC, is an expert in 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.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Injury Management Results (IMR) Software: https://imrsoftware.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.