How Spinal Fusion Can Create New Complications

Several weeks ago, I wrote about two of the most dreaded words in workers’ compensation. The words “spinal fusion” can represent a significant problem in addressing workers compensation cases. With the assumption that the need for a lumbar fusion has been adjudicated, and the perceived need is a function of the compensable event, one must realize that in an effort to address these pain complaints, a solidly healed spinal fusion may ameliorate the symptomology (or relieve the symptoms noted). What needs to be incorporated into the mindset of the claims professionals is that with this fusion, normal spinal anatomy is compromised, and the stressors normally encouraged at the level(s) involved is translated either above or below.

Red Flags for Adjacent Segment Diseases

Therefore, one of the long-term unfortunate consequences of a spinal fusion is a disease process known as adjacent segment disease. Clearly, if there is adjacent segment disease identified at the time of injury, this is a clear indicator of a long-standing, pre-existing, and unrelated comorbidity. However, if this particular pathology is identified months or years after the noted fusion, this represents a significant complication. The clinical literature notes that between 5% and 30% of the patients will develop this process after spinal fusion.

This is not a new disease; however, this diagnosis represents an additional degenerative change in the region of the spine compromised by the surgical fusion. One must be clear that the pathology is not limited to x-ray findings alone; the noted findings must be combined with appropriate clinical examination demonstrating objectified symptomology (or clinically confirmed symptoms) at the proximal or distal level. To be clear, this complication can occur months or years after the surgical intervention.

In Texas, the clinical standard is that all care reasonably required to address the sequelae of the compensable event must be treated. The original injury must be a “producing cause” of the current pathology. Therefore, a successful lumbar fusion, one that has noted to have reached maximum medical improvement, has been assigned an impairment rating, and the claim has been closed; this individual can return seeking an additional surgical intervention to address this pathology. And if adjacent segment disease has been objectified, you as the claim file handler must engage this diagnosis and provide appropriate treatment.

Questions That Must Be Resolved

If such a scenario lands on your desk, a careful analysis of all cogent facts must be completed to ascertain that this is clearly adjacent segment disease that has been objectified both from a physical examination perspective, and a diagnostic perspective, and is clearly a function of the compensable injury sustained. One must confirm the original injury, confirm that surgical intervention with a solid fusion had occurred, that the pain complaints are at a different level than the original injury, and the identified degeneration of an adjacent level was not previously symptomatic. While not ruling out this diagnosis, a careful clinical assessment needs to be obtained to ascertain if this particular finding is in fact related or a sequela of the compensable event.

One must ensure that the detailed clinical history provided includes several factors. These would include a clinical analysis of degeneration at adjacent level before the fusion, are the current symptoms anatomically consistent with the adjacent segment (note the nerve root function and corresponding findings), is there a cogent clinical argument explaining and linking the previous fusion to the current newer pathology. An additional consideration is whether there are noted comorbidities such as age, obesity, tobacco consumption, multiple level fusions or other risk factors. One must note if all non-operative options been fully explored.

As soon as this file lands on your desk, initiate a comprehensive, evidence-based medicine review so that the appropriate determination of adjacent segment disease can be established as opposed to a coincidental degenerative pathology.

The Bottom Line on Adjacent Segment Disease

Bottom line, adjacent segment disease is very real. However, it is not an automatic or inevitable sequela of lumbar fusion surgery. Your investigation has to include a careful analysis of the anatomy involved, the biomechanics, the clinical presentation, and timing of the symptomology. If you, as the adjuster, fully understand adjacent segment disease, and ask the appropriate questions, you will be in a better position to assign medically defensible claims decisions.

Why Claim Resolution Often Goes Off Track

Obtaining a resolution for a compensable injury is the ultimate goal of every workers’ compensation professional. However, the path to closure is rarely a straight line. Between clinical hurdles, occupational rehabilitation issues, and administrative friction, the process is often bogged down by “tangential factors” that distract from the primary objective.

A key component of this process is establishing a return-to-work (RTW) plan in a manner that is as safe and efficient as possible. Effective work restrictions must balance three critical elements:

1. The safety of the injured individual.

2. The physical ability to complete assigned tasks.

3. Objectified clinical standards that ensure the employee’s long-term health is never compromised.

The Problem: The “Vague Language” Trap

I recently reviewed a file with poorly communicated work restrictions that created a domino effect of issues. It muddled the claim process, compromised the treatment plan, and delayed compliance from both the employee and the employer.

The breakdown usually happens because of a lack of a standard format. We often see providers use non-specific terminology like “light duty,” which is virtually meaningless to an employer. There is a massive functional difference between “no lifting over 25 pounds” and the vague suggestion of “taking it easy.”

The Provider as the Gatekeeper

The foundation of any effective work restriction is a clear understanding of specific job standards. The treating provider acts as the gatekeeper. To do this job effectively, they must:

• Request Functional Language: Move away from “light duty” and toward precise functional capacity (e.g., “cannot reach above shoulder height with the right arm”).
• Review Job Descriptions: A provider cannot accurately restrict a worker if they do not know what the worker actually does. If a worker sorts eggs from a seated position, a “no prolonged standing” restriction is irrelevant.
• Validate Correlation: Does the restriction actually match the injury? (For example, restricting upper extremity use for a stubbed toe is a red flag).

The Employer’s Role: Preparation and Clarity

Employers often miss opportunities for early RTW because they have not done the groundwork. An employer’s obligation is to ensure that restrictions are accurately and rapidly applied. This requires:

• Comprehensive Job Descriptions: Including specific physical tests or requirements.
• Modified Duty Blueprints: Having a plan for “meaningful work” before the injury even happens.
• Direct Communication: If a restriction is unclear, the employer should feel empowered to call the provider (or the adjuster) for clarification rather than simply saying, “We can’t accommodate that.”

The Claims Professional: The Connective Tissue

As the claims handler, you are the link between the employer and the injured employee. You must be proactive rather than reactive.

• Get the Job Description Early: Do not wait for a permanent impairment rating to ask what the worker does for a living. Have the job description in the file from Day 1.
• Identify Mismatches: If the restrictions do not match the injury or the job description, pick up the phone. A quick call to the provider can often resolve a dispute before it turns into a litigated mess.
• Utilize Case Management: If the gap between the provider’s intent and the employer’s capability is too wide, involve a Nurse Case Manager to act as a clinical conduit.

The Bottom Line: Standards for work restrictions are not just more “bureaucracy.”

They are a protection for everyone involved. When we use precise language and objective standards, we protect the employee from re-injury and the employer from administrative burden.

By fostering forward-looking communication and educating the injured employee on the why behind their restrictions, we improve outcomes and reduce the likelihood of litigation. It is more than just paperwork, it is a demonstration of professionalism and a commitment to the recovery of the human being at the center of the claim.

A framework for making education spend defensible, not discretionary

Training budgets get cut first. Not because they matter least, but because they are usually presented as if they matter least. When a budget staffer or committee is trimming for the year, discretionary line items go before core operating costs. If professional education shows up in your budget package as a discretionary line, it will be treated as one, regardless of what it actually does for your claim’s outcomes. The realized expense comes next.

The fix is not a stronger pitch. Enthusiasm does not survive a budget cycle. What survives is a document that reads the way the rest of the finance package reads: a named cost tied to a named, measurable outcome, with a downside the reviewer can quantify if the money disappears.

Why the Wish List Format Fails

Most training requests are built as a materials list. Number of courses, number of seats, cost per license. That format is easy to cut, because nothing in it tells a CFO what happens to claim performance if the request is denied. A line item with no connected consequence is, by definition, discretionary.

Compare that to how the same CFO evaluates a claims system upgrade or a new panel vendor. Those requests come with a stated mechanism: fewer manual touches, faster cycle time, lower unit cost. Training deserves the same treatment. The mechanism is not new. The presentation usually is the problem.

What a Defensible Request Contains

1. Name the claims metric, not the training activity. Do not ask for budget to “deliver adjuster education.” Ask for budget to move litigation rate, claim duration, reserve accuracy, or reopen rate, and name the training as the mechanism.
2. Quantify the downside with real data, not internal opinion. WCRI’s analysis of more than 950,000 lost-time claims found that attorney-represented claims cost $7,700 to $12,400 more than comparable non-represented claims (Monnin-Browder and Telles, WCRI). Industry leakage audits consistently place unnecessary claim spend at 5 to 15 percent of paid losses, much of it traceable to adjuster decision errors. Those numbers, not the training catalog, are what earns attention.
3. Scope it as a pilot, not an organization-wide rollout. A request for a controlled group, with a comparison against adjusters who did not receive the training, is far easier to approve than a blanket ask. This is the same logic finance teams already use in zero-based budgeting: fund the smallest version that can prove itself, then expand.
4. Set a review date and name the metrics you will report against. Six to twelve months, tied to the same claims data the organization already tracks. A request with a built-in checkpoint reads as accountable. A request with no checkpoint reads as an ongoing commitment, which is exactly what gets cut when budgets tighten.
5. Show the cost of doing nothing next to the cost of the program. Reviewers do not compare your request to zero. They compare it to the alternative, which is the claim outcomes you already have. Put both numbers on the same page.

A Worked Comparison

Consider a mid-size TPA with 40 adjusters and a structured training investment of $2,000 per adjuster, or $80,000 annually. Compare that to a single additional represented claim per adjuster per year, a documented and common consequence of inconsistent claims handling. At the low end of the WCRI figure, $7,700 per claim, that is $308,000 in avoidable litigation cost across the desk. The training line is not competing with a hypothetical benefit. It is competing with a number that is already showing up in the loss run.

This is the comparison a budget committee understands, because it is the same comparison finance already runs on every other line item. Tool spend gets measured by the outcome it changes. Training spend should be measured the same way.

Tool Spend Versus Competence Spend

Most organizations can produce a clean ROI case for a new claims platform, a bill review tool, or a network contract. Fewer can do the same for training, not because the case is weaker, but because it is rarely built with the same discipline. A technology purchase gets a usage report. A training program gets an attendance sheet. One measures activity. The other should measure competence, and competence is what actually moves the claim file.

A budget committee does not protect the line items it likes best. It protects the line items it cannot explain cutting. Build the training request so that cutting it requires the committee to explain, in writing, why it is comfortable absorbing $300,000 in avoidable claim cost to save $80,000 in program spend. Most will not choose to write that sentence.

About WorkCompCollege.com

WorkCompCollege.com offers structured, specialty education protocols built for professionals working across the workers compensation ecosystem. If you are preparing a training budget request for the next planning cycle and want a curriculum that maps directly to claims performance metrics, it is worth reviewing what is available at WorkCompCollege.com.

 Sources

• Monnin-Browder, William, and Carol A. Telles. Impact of Attorney Representation on Workers’ Compensation Payments. Workers Compensation Research Institute (WCRI). wcrinet.org
• Amaxx Risk Solutions. Control Your Workers Comp Leakage. reduceyourworkerscomp.com
• WorkersCompensation.com. Leakage Audits Find 19 Types of Workers Compensation Claim Leakage. workerscompensation.com
• National Council on Compensation Insurance (NCCI). 2025 in Sight, 2024 in Review. ncci.com

A Line-Item Breakdown

Adjuster turnover tends to get filed under human resources. That is a mistake. When a trained claims adjuster leaves your organization, the financial damage does not stay in the HR budget. It spreads across your loss ratio, your reserves, your litigation rate, and your claim duration numbers. It shows up everywhere except the place where you were looking.

CFOs and VPs of Claims routinely underestimate the true cost of replacing an adjuster because they see only the line items that accounting tracks. What they miss is larger, and it sits in the claim file.

Most organizations have some handle on the direct costs of turnover. Recruiting fees range from 15 to 25% of annual salary for a mid-level adjuster position. Add background screening, onboarding administration, benefits setup, and the time your supervisors spend interviewing candidates rather than reviewing claims. A conservative estimate for a single adjuster replacement runs between $8,000 and $15,000 before that person has handled a single file. With the understanding that these numbers are uncomfortable, but they are not what should concern you most.

The real cost of turnover is not on the HR balance sheet. It is inside every claim file a new adjuster touches during the first six to twelve months on the desk.

Ramp time is the first problem. The Society for Human Resource Management (SHRM) estimates that it takes an average of six months for a new employee in a skilled role to reach full productivity. For a workers compensation adjuster, that productivity gap translates directly into claim file handling quality. Delayed initial contact, incomplete medical management, missed subrogation opportunities, and slower reserve adjustments are not abstract risks. They are common ramp-period behaviors that inflate claim costs.

The Workers Compensation Research Institute has consistently documented that early, consistent claim management correlates with lower medical costs and shorter claim duration. An adjuster who is still learning your protocols, your jurisdictional rules, and your vendors is not delivering that early management. The claim pays the difference.

Shadow training is the second problem. Organizations rarely count it as a cost, but it is one. When a new adjuster arrives, experienced adjusters become informal trainers. That time is not free. It reduces the caseload capacity of your most experienced people precisely when you need them most. In shops with chronic turnover, the senior adjusters spend a meaningful portion of their week coaching the newest hire rather than managing complex claims.

Litigation exposure is the third problem, and the most expensive. Adjuster inexperience is a documented driver of attorney involvement. When adjusters fail to make timely contact, miss deadlines, or communicate poorly with injured workers, attorneys notice. A 2019 analysis by NCCI found that attorney-represented claims cost three to four times more than non-represented claims, after controlling for injury severity. Inexperienced adjusters do not create this disparity intentionally. They create it through errors of omission that a trained, experienced adjuster would not make.

Reserve inaccuracy is the fourth problem. New adjusters tend to set conservative initial reserves and then adjust upward repeatedly as the claim develops. That pattern creates adverse development on your loss triangle, inflates IBNR estimates, and weakens your actuarial position at renewal. Reserve adequacy is a competency that takes time to develop. Turnover resets that competency continuously.

 Adding It Up: A Rough Line-Item Model

Consider a mid-size TPA or insurer that loses 20% of its adjuster staff in a given year. For an organization with fifty adjusters, that is ten replacements. Assign conservative numbers to each cost category:

• Direct replacement cost per adjuster (recruiting, onboarding, HR administration): $12,000
• Lost productivity during ramp period (six months at 60% capacity on a $65,000 salary desk): $19,500 in equivalent claims management output
• Senior adjuster shadow training time (estimated 15% of senior adjuster hours for three months): $4,800 per new hire
• Claim leakage from ramp-period errors (conservative 3% excess on a $400,000 average caseload): $12,000 per adjuster per year
• Increased litigation exposure from inexperience-related mishandling (estimated 1 additional represented claim per adjuster per year at $25,000 excess cost): $25,000

That puts the conservative all-in cost of a single adjuster replacement at approximately $73,000. For ten replacements in one year, the organization is absorbing more than $700,000 in turnover-related cost, the majority of which never appears in the HR budget. The number that appears in the HR budget is $120,000.

The benefits of training. Retention and training are not separate strategies. Research from the Association for Talent Development and multiple insurance industry surveys shows that employees who receive consistent professional development are significantly more likely to stay with an organization. The mechanisms are straightforward: trained adjusters feel more competent, take on more complex work, earn performance recognition, and develop professional identity within the organization. Those are retention anchors.

Training also shortens the ramp curve. An adjuster who enters your organization with current, structured education in claims management, medical management, and jurisdictional law reaches full productivity faster. That compresses the ramp-period leakage window and reduces the burden on senior adjusters.

The math is not complicated. A structured annual training investment of $1,500 to $2,500 per adjuster is a known, controlled expense. The alternative, absorbing $70,000 or more when that adjuster walks out the door, is an uncontrolled one.

The reason turnover costs stays invisible is that most organizations do not measure it. HR tracks time-to-fill and replacement cost. Finance tracks budget variance. Nobody is connecting the new adjuster’s first-year claim outcomes to the cost of turnover.

If you want to make this argument to a CFO or a board, you need a measurement framework that connects adjuster tenure to claim performance metrics: average claim duration, litigation rate, reserve accuracy, and reopen rate. When you run that analysis, experienced adjusters outperform new adjusters on every variable. That performance differential is the financial argument for retention, and retention is the financial argument for training.

SOURCES

• Society for Human Resource Management (SHRM). Retaining Talent: A Guide to Analyzing and Managing Employee Turnover. shrm.org
• Workers Compensation Research Institute (WCRI). Predictors of Outcomes in Workers Compensation. wcrinstitute.org
• National Council on Compensation Insurance (NCCI). Attorney Involvement in Workers Compensation Claims. ncci.com
• Association for Talent Development (ATD). 2023 State of the Industry Report: Workforce Learning and Development. td.org
• Amaxx Risk Solutions. The True Cost of Workers Compensation Adjuster Turnover. reduceyourworkerscomp.com

I am not sure why this popped into my head, but I was thinking about a song from the mid-80s from Dire Straits, the song “Money For Nothing” in the first line (and I will take the creative license with the lyric) “Money for nothing and your ‘checks’ (my bad) for free.” It seems a frequent consideration that a percentage of work comp claims are perceived as being embellished, fraudulent, or otherwise considered as a winning scratch off ticket. We know this is not the case, however, it must remain a possible consideration.

When a Workers’ Compensation Claim Begins to Change

Over my years as a cost-containment professional, I cannot tell you how many times we have seen this scenario. The claim starts relatively straightforward, and with time and multiple additional conversations, the claim becomes something completely different. Initially, we usually get a baseline. Then things change. We may get body parts reported to be part of the injury, ongoing symptomology that does not coincide with the objective clinical data provided, and the overall situation worsens as opposed to improve given the treatment rendered. At times, the treatment escalates without any specific objective clinical rationale to support this increase in complaints.

The Importance of Objective Clinical Evidence

One of the advantages you, as an experienced claim file handler, have is your experience. You can see what the original complaints were, noting the original mechanism of injury, yet the overall symptomology increases. What will help you most dramatically is having that objective clinical assessment ascertaining what actually occurred because of the identified event.

As I think about this, it became abundantly clear that you as a Worker’s Compensation professional must protect the claim integrity from day one. There are any number of tools available, however the one most beneficial and cost-efficient is our Baseline Clinical Assessment (BCA). A Baseline Clinical Assessment lets you know what pathology yours is, and more importantly, what noted symptomology or other pathology is not a function of the identified event. Having that medical assessment in your back pocket enables you to spot those red flags.

At times, I call this a Claim Drift Phenomenon. One would strongly suggest that every claim file professional watches for these “drift” indicators:

• changes that do not match the medical evidence
• there is frequent or high-cost treatment utilization
• there are noted behaviors and reporting inconsistencies such as missed appointments
• shifting symptoms or escalation in the reported mechanism of injury (e.g., a 20-pound box becomes an 800-pound log with one other individual)
• the continued use of opioids without noted improvement in the overall clinical situation or pain score.

Any of these should be the initiation of a comprehensive assessment relative to the current state of the claim file.

What should you do? The answer is easy, obtain competent, objective, and independently confirmable medical evidence to support the clinical situation. If none is available, take every available step to objectively define and document the exact extent of the compensable injury as it actually occurred. Let the BCA be your clinical foundation for doing just this.

Understanding the Difference Between Claim Drift and Fraud

The bottom line is that not all deviations from the normal constitute fraud. Unfortunately, this does occur, however, before you pull the trigger ensure that the clinical facts support your determination. Narratives change. Appropriate treatment can escalate depending on additional clinical facts. Communication between the treating provider and you may not be optimal.

However, when you have a comprehensive objective clinical assessment noting the exact sequelae of the identified mechanism of injury, (at the time of the initial injury) when the overall claimant drifts away, there needs to be specific objective data to support this drift. An earthquake in the middle of the Pacific Ocean can cause a tsunami in Japan. However, one is able to objectify that earthquake, and without such data that tsunami does not appear to be a function of the noted event. Preparation before the tsunami hits in the form of a Baseline Clinical Assessment may be your best insurance against those damages.

The numbers on adjuster turnover are not surprising once you see them. What surprises CFOs is the calculation they have never run: the full cost of losing and replacing a trained workers compensation adjuster, compared to the cost of keeping one through structured professional development.

The research is consistent. The Society for Human Resource Management estimates that replacing a mid-level employee costs between 50% and 200% of annual salary. For an experienced adjuster earning $65,000 to $85,000 per year, that is a replacement cost of $32,500 to $170,000 per departure. At the higher end of that range, losing three adjusters in a year quietly removes a quarter million dollars from your operating budget before you have posted a single open position.

Those numbers do not account for what happens to the claims during the transition.

What Turnover Actually Costs on the Claim Side

When an experienced adjuster leaves, the claims they carried do not pause. They transfer to someone else, often someone newer, who must reconstruct the file from scratch. Notes that were never entered, relationships with nurse case managers that did not transfer, negotiations that were in progress but not documented, all of these become financial exposure.

WCRI has documented that claims handled by less experienced adjusters tend to have longer durations and higher costs than comparable claims managed by their senior counterparts. That gap is not about effort. It is about clinical pattern recognition, communication discipline, and decision-making under uncertainty. Those things come from experience. They also come from training. And they leave when the adjuster does.

A claim that gains 30 days of additional duration because of a management transition is not an abstraction. If average medical costs runs between $2,000 to $3,000 per month and you carry 150 open claims per adjuster, even modest duration increases produce significant leakage. Multiply that by your annualized turnover rate and the math becomes difficult to ignore.

Why Recruitment Spend Rarely Closes the Gap

The instinct when turnover rises is to recruit. Post the role, hire the candidate, onboard the person, and move forward. This feels like problem-solving. It is actually the most expensive response available.

Experienced adjusters do not come off a shelf. The pipeline is constrained. Experienced candidates want competitive compensation. Training them on your systems, your vendors, your protocols, and your client relationships takes three to six months at minimum. Research from industry sources including Amaxx, suggests that informal shadow training, where a new hire follows a veteran until they learn the job, costs more in the veteran’s lost productivity than organizations typically estimate. You are not hiring a replacement. You are hiring a starting point.

Training as Retention Infrastructure

The research on why workers leave is consistent across industries. Compensation matters. So does feeling competent and respected in the role. For adjusters, those two things often come down to the same question: does this organization invest in my ability to do this job well?

An organization with structured continuing education, defined advancement paths, and recognized credentials sends a clear message that professional growth is part of the employment relationship. That message matters to experienced adjusters who have options.

WCRI has studied claim outcomes by adjuster experience and caseload. NCCI has examined the relationship between adjuster competency and claim cost. The pattern that emerges is consistent: competence drives outcomes, and competence is not accidental. It is built over time through practice, feedback, and structured learning.

Training programs that produce recognized credentials give adjusters something tangible. They also give their employers something: a professional identity that employees think twice about walking away from.

Building the Retention ROI Case

The calculation is not complicated. Start with your annualized adjuster turnover rate. Multiply by average replacement cost using the SHRM framework. Add estimated claims leakage from coverage gaps and experience loss during transition periods. That is the cost you are already absorbing.

Then compare it to the cost of a structured professional development program. A well-designed continuing education budget runs $500 to $2,500 per adjuster per year, depending on certification levels and program depth. If that investment reduces turnover by even one departure per year in a team of twenty, the return typically exceeds the program cost by a factor of five to ten.

The objection that almost always follows is: what if we train them and they leave anyway? It is a fair question. The answer is what happens if you do not train them and they stay.

A Note on Measurement

Most organizations measure training success by attendance counts and satisfaction scores. Those metrics tell you who showed up and how they felt about the experience. They do not tell you whether the training has changed anything on the claim.

Retention ROI requires a different scorecard. Track turnover rate by team and tenure band. Track claim duration and reserve accuracy by adjuster experience level. Track time-to-close comparisons between experienced adjusters and those within their first 18 months. Connect those numbers to your training investment over 12 to 24 months. When that analysis is in front of a CFO, the conversation changes. You are no longer asking for a training budget. You are presenting an infrastructure decision.

The Practical Starting Point

Organizations that have made this shift typically start the same way. They identify the five to ten adjusters most likely to leave in the next 12 months, based on tenure, caseload, and compensation relative to market. They design a targeted development offer around those individuals. They track outcomes over 18 to 24 months.

The results tend to confirm what the research already shows: people who feel professionally invested in do not leave as readily, handle claims more consistently, and generate fewer correctable errors that compound into leakage.

WorkCompCollege.com was built around exactly this model.

The curriculum connects education directly to claim outcomes, and the programs are designed for professionals already doing the job, not studying for a career change. If you are building a retention and development framework for your claims organization and want to understand how professional education maps to those outcomes, it is worth a look.

Litigation in workers’ compensation is often discussed as if it were an external force. Advertising trends. jurisdictional differences. social dynamics. All of those factors play a role. None of them are where most claims actually change direction.

Litigation is rarely random. It is a downstream effect of earlier decisions.

If you want to understand what fewer attorney-involved claims mean to your loss ratio, you have to start with a simple equation. Attorney involvement increases costs. Therefore, reducing attorney involvement improves outcomes. The question is not whether that is true. The question is why it happens.

Early on after SB1 in Texas, it was noted that overall costs were reduced by 40%. As I was speaking with an Office Manager for the then TWCC, he was boastful, until I pointed out that this represents the near total elimination of plaintiff attorneys from the Texas work comp system.

There is useful data to ground this discussion. A study summarized in a prior blog, attorney involvement increases payments by approximately 7,700 to 12,400 dollars per claim, increases lost time duration by 284%, and raises expense payments by roughly 200%. Those are not marginal shifts. They fundamentally alter the cost structure of a claim.

From a loss ratio perspective, this creates two simultaneous pressures. Claim severity increases, and claim duration extends. Both drive total incurred upward. Neither is easily reversed once litigation is established.

The more useful question is when the decision to retain an attorney actually occurs. It does not typically happen at the moment of injury. It occurs later, often within the first 30 to 90 days of the claim, after a sequence of interactions that shaped the injured worker’s perception of the process. I have talked about this previously. The decision to seek counsel often follows confusion, lack of clarity, or a breakdown in communication rather than a single discrete event.

That timing matters because it reframes litigation as a process issue rather than a legal inevitability. The practical implication is straightforward. Litigation reduction is an early claim handling function. Consider how that plays out on a file.

The claim begins with a mechanism of injury. That mechanism defines what should and should not be considered part of the compensable event. If that boundary is not clearly established, the claim begins to drift. Additional complaints are incorporated. Treatment expands without a clear clinical anchor. The file becomes harder to manage and more difficult to defend.

Once that ambiguity exists, disputes are more likely. Disputes invite legal involvement. The inverse is also true. When the mechanism is clearly defined, symptoms are evaluated in relation to objective findings, and treatment is aligned with expected recovery, the claim remains controlled. Communication is more consistent. Expectations are clearer. Fewer disputes emerge.

This is not a legal strategy. It is clinical and operational discipline applied early. There is also a structural component to consider. Litigation rates vary significantly by jurisdiction. In Gameplan, litigation involvement is estimated at approximately 65% in some environments and closer to 15% in more structured systems with defined processes and controls.

That spread is not accidental. It reflects differences in how claims are directed, how care is managed, and how decisions are documented and communicated. For claim leaders, the takeaway is direct. Litigation rates should be treated as a controllable metric, not a fixed cost of doing business.

From a measurement standpoint, litigation rate belongs alongside:

1. Claim duration
2. Medical cost per claim
3. Reserve accuracy
4. Reopen rate.

It is one of the few metrics that influences all the others at the same time. Reducing litigation does not just remove legal expenses. It compresses duration, stabilizes reserves, and limits unnecessary treatment expansion.

There is a point worth stating plainly. The legal process itself is not the primary cost driver. It is the conditions that lead to legal involvement that create the identified exposure. Those conditions are largely established early in the claim. For that reason, the most effective litigation reduction strategies are not reactive. They are front loaded.

They include:

1. Clear definition of the compensable injury based on mechanism.
2. Early alignment of treatment with objective clinical findings
3. Consistent, plain language communication with the injured worker
4. Documentation that explains decisions, not just records them.

None of these steps require additional complexity. They require consistency.

When executed well, they reduce uncertainty for the injured worker and defensibility risk for the employer. Both factors directly influence the likelihood of attorney involvement. The loss ratio impact is not subtle. Fewer attorney-involved claims mean lower average cost per claim, shorter duration, and fewer late-stage surprises in reserve development. It is one of the cleanest levers available in cost containment. Better early decisions produce fewer disputes. Fewer disputes produce fewer attorneys. Fewer attorneys produce better numbers.

That is the equation.

In our professional careers within the workers’ compensation ecosystem, how many times have we seen the most straightforward injury or claim file become one of the most problematic scenarios imaginable? The reported injury is relatively simple: a warehouse employee missteps and sustains an ankle inversion event, resulting in a modest ankle injury. The initial clinical evaluation included plain radiographs, which revealed no fractures or other osseous abnormalities. Given the findings of swelling and painful motion, it was clear that the actual injury sustained was a Grade II sprain of the anterior talofibular ligament.

When a Simple Injury Becomes a Complex Claim

Treatment for a modest ankle sprain is straightforward—a period of immobilization, gentle range-of-motion activities, and gradual progression to a slightly more aggressive physical therapy protocol. Within four to six weeks, this injury should be fully resolved.

The problem is that the injured individual has not returned to work, claims they cannot walk, and appears intent on prolonging the claim indefinitely. What factors could be preventing resolution of this claim with a return to work?

One possibility is catastrophizing: “I’ll never walk again or return to work again.” Another could be fear-avoidance: “Any pain means a second injury or worsening damage.” There may also be a perceived injustice—perhaps the injured employee has seen too many plaintiff attorney advertisements on television promising million-dollar settlements. The key takeaway is that this scenario is not extraordinary; these reactions are common human responses to trauma that can stall recovery. To be clear: pain does not equate to pathology. Delayed recovery does not indicate structural failure. Most importantly, early assessment of psychological flags within the claim file can serve as strong predictors of prolonged disability.

Psychological Barriers to Recovery

Each claims professional in the workers’ compensation system must embrace the biopsychosocial shift in how today’s injuries are addressed. Under the old model, the standard was “Injury + Treatment = Return to Work/Case Resolution.” Today, however, a comprehensive biopsychosocial perspective is necessary—especially when dealing with cases that are less than straightforward. The modern claims handler is no longer simply administering indemnity payments and medical benefits; they directly influence the recovery and resolution trajectory.

Workers’ compensation professionals must acknowledge this evolving aspect of the injured individual’s experience. Every claims handler should cultivate a foundational knowledge of biopsychosocial principles. Understanding tangential factors that may compromise a file early on leads to far better outcomes—outcomes that are significantly less expensive than those stemming from prolonged litigation.

For seasoned professionals, several practical strategies can make a substantial difference. As mentioned in previous blogs, increasing communication frequency with the injured employee is imperative. Apply the principles of active listening. Pay attention to “I” statements or emotionally charged phrasing during conversations. Avoid terms such as “investigating,” and instead use language like “supporting recovery,” emphasizing that your mission is to ensure all care reasonably required to address the sequelae of the compensable injury is being pursued. With your experience, do not hesitate to suggest that the injured employee explore additional resources or interventions when appropriate to achieve comprehensive resolution of the injury.

What Separates Good Adjusters from Great Ones

One final thought: embracing the concept of biopsychosocial intervention is not a soft skill. It is a key determinant in achieving the best possible outcome for the injured employee. Focus on the injury, seek to understand the individual’s perspective, and take note of personal factors that may compromise recovery. Developing these skills—and incorporating them into daily practice—is what separates good adjusters from great ones. It is well-documented that improved outcomes for injured employees reduce overall costs and benefit all parties involved.

It has been my experience that most C suite executives assume initial and ongoing training for workers compensation claim file handlers is a “discretionary soft expense.” This determination is incorrect and deserves a second look. An individual who is not trained, making significant decisions often produces measurable and avoidable claim cost inflation.

I would like to ask each of you to run one additional calculation before you reach a final position on that particular determination. The result is not what you might expect.

Simply stroll through the four separate cost centers that untrained claim file handlers might generate. This path would include reserve errors (both over and understated) that is a function of a lack of clinical understanding. An adjuster who cannot distinguish between an acute injury and underlying degenerative disease may reserve based on findings noted on imaging studies and not the clinical sequelae of the compensable event.

Additionally, not understanding the clinical aspect of the injury sustained can lead to approval of treatment not related to the identified injury. Moreover, a lack of familiarity in terms of claim duration and what is to be expected extends the injury beyond the clinical standard. There is a saying in orthopedic medicine that all bones heal, it is a function of time. Failing to understand this concept will lead to protracted duration scenario.

It is also noted that at times, litigation is triggered by less than defensible determinations made. These difficult to defend determinations are often a function of incorrect or inappropriate documentation. Each of these four items has a specific monetary impact on the file being addressed.

Here is a simple formula on which you can complete your calculus. The average claim cost multiplier from extended duration times the annual claim volume times percentage attributed to the adjuster decision quality and this would equate to the annual leakage estimate.

As an example, a midsize employer with approximately 200 lost time claims per year would be a conservative multiplier. The net result plans in the mid-six figures prior to litigation costs. The expense of the untrained adjuster is very real.

The solution to this problem is simply known as education. Reducing the cost per claim is a straightforward reduction tool solely based on the skill set of that trained claim file handler (CFH). The literature notes those CFH who have a more than cursory understanding of clinical reasoning close files faster, can establish reserves more accurately, and generate fewer unnecessary referrals.

When you effectively communicate with experienced and trained CFH, you can easily recognize the value that ongoing training provides. While noting this is somewhat anecdotal and noting there is no single peer-reviewed study measuring cost savings from trained persons untrained individuals, our collective experience demonstrates the overall utility of having ongoing education as part of the job description of each level of claim file handler.

Some argue (Amaxx & similar claims consulting sources) that the “claim leakage” runs between 5 and 15% of total losses paid. The single largest contributor to this leakage has been attributed to adjuster decision errors.

An additional reference would be WCRI who notes that “an adjuster who does not understand clinical milestones cannot intervene at the right moment.” This lack of education/understanding translates into significant dollars (WCRI Study: Key Factors in High-Cost Claims)

In short, just like the medicine we must endure in treating injuries has changed and continues to evolve, the overall methodology to handle files at the earliest level also continues to evolve. Education in this contest is not abstract. The CFH must be able to evaluate the entirety of the claim from clinical issues, sort out symptomology from objective findings, note expected recovery timelines, as well as other tangential patterns. Ongoing training is often categorized as an expense; however, in practice, this training is a form of loss control. The education requirement is ongoing and failing to do so can become expensive. Every claim will incur costs; the only variable is how much of these costs are driven by the injury versus those costs driven by a lack of appropriate education/training. To be clear, the difference is not subtle, and is easily measured in dollars.

As a claim file handler in the workers’ compensation ecosystem, you and your team are not merely passive administrators of the noted claim. It is my belief you have a fiduciary responsibility to apply every aspect of the statute, working in the interests of both the injured employee and your client the employer. Essentially, you as the claim file handler, are the gatekeeper for medical interventions, financial accuracy, and adherence to every aspect of the applicable statute/rules.

One of the most powerful tools in your armamentarium is the application and utilization of the standards, as noted from an evidence-based medicine perspective. During your review of the medical records, and paying note to the past medical history, there might be little tidbits demonstrating pre-existing pathology. The question becomes, was this pathology, in any way, compromised by the reported mechanism of injury? 

Understanding you are not a medical clinician, what you should be obtaining is an independent, objective, comprehensive summary of the medical records presented, designed to establish not only what is a function of the reported mechanism of injury, it is imperative to note what specific findings are not related to the compensable injury.

With modern imaging technology and techniques, degenerative findings can often be distinguished from acute trauma based on morphology, severity, and chronology. With this information you can state with a measure of certainty that some of the clinical findings were, in no way as a function of the identified injury, compromised by the identified event. Using this data, and your understanding of the regulatory frameworks in your specific jurisdiction, this leads to responsible claim file management and a clear direction for the injured individual to take to achieve resolution of the injuries sustained.

What Is an Evidence-Based Medicine Challenge?

Evidence-based medicine integrates the best available clinical research related to the injured employee based on their clinical records. When a specific clinical provider provides a diagnosis, there should be clear objective clinical data correlating the pathology with the reported mechanism of injury. A simple ground-level fall onto the lateral aspect of the right hip did not cause, and clearly did not exacerbate, bone-on-bone arthritis in the contralateral uninvolved left hip.

With this comprehensive clinical evaluation, you are obtaining a thoroughly medically defensible chain of reasoning, establishing the exact diagnosis that resulted from the injury, which would exclude any number of pre-existing and otherwise unrelated comorbidities that may be present. With this medical rationale being objectified, you can contest the extent of injury or otherwise controvert those findings that may lead to extensive interventions, treatments, total joint replacement protocols and in some jurisdictions, exposure for lifetime medical treatment.

Issues such as multiple-level degenerative joint disease do not occur after a single event. Cervical spondylosis or sclerosis, which may need surgical intervention, is clearly not a function of a simple slip and fall. Similarly, a minor knee contusion in an obese 63-year-old individual does not become a “meniscal tear requiring arthroscopy.” Another question that needs to be resolved is if there is a clear clinical correlation between any psychiatric diagnosis, consistent with the parameters noted within the DSM-5, relative to any late onset reported sequelae of the compensable injury should be examined in detail.

A recent cursory search noted that approximately 15% of employed individuals do not have health insurance. This is not to say they do not have clinical issues, only that those noted issues are most probably not a function of or otherwise compromised by the reported mechanism of injury. This is where “injury creep” becomes an issue to be addressed.

As an example, in Texas one simply needs to obtain a detailed review of the clinical records, and with this report, complete a PLN-11 establishing what the accepted compensable injury is noted to be, and what comorbidities are clearly unrelated to the injury sustained.

In Louisiana, the form to be completed is LWC-1002. This form enables individuals to accept the injury and at the same time contest objectified unrelated pathology when there is no specific data indicating any damage or harm occurred for the pre-existing pathology. This would significantly reduce surgery to address the unrelated comorbidity as a function of the compensable event.

In Georgia, the process is a tad more complicated. The key point is that with an objective report noting the sequelae of the identified event, and any other pathology identified, completion of form LW-3 allows for controversion of specific pathology without controverting the entire injury. If necessary, after this form is submitted, appropriate clinical evaluations may be necessary but establishes that certain elements of the pathology are not a function of the identified event.

Strategies for Claim File Handlers

Successfully contesting pathology requires a structured approach: 

1. Obtain all medical records possible, specifically those recorded in the emergency room, occupational medicine clinic, or the initial clinical evaluation.
2. Pay particularly close attention to the reported mechanism of injury, the presenting complaints (specifically the location of the pain), the past medical/surgical history, and the review of systems.
3. At approximately 30-45 days from the date of injury, seek a clinical assessment from an objective independent source identifying the actual sequelae of the compensable event as well as notification of all identified pathology that pre-existed the reported injury sustained.
4. Pay particular attention to the clinical citations offered supporting the determinations made.

As I have seen on too many occasions, poorly supported diagnoses, or overly vague diagnoses, can easily inflate overall claims cost, duration of disability, unnecessary or excessive surgery, and precipitate uncalled-for litigation. Reliance on the standards of evidence-based medicine restores integrity in the overall claims process, establishes a level of fairness in providing all of the appropriate care of the injured employee, notes compliance with the statutory requirements, and provides that claim file handler with clinical data necessary to communicate to the injured employee and treatment team, which should expedite claim resolution. What all parties see are the objective basis for the determinations made, this should lead to fewer disputes.