Hidden cost drivers in workers’ comp claims can quietly erode your loss ratio, here is how to spot them fast. As we all know, in workers’ compensation, the difference between an acceptable loss ratio and a disastrous one often hides in plain sight within your claims files.

While most adjusters focus on obvious red flags like overtreatment or surgical authorizations, the real cost bleed happens quietly through systemic inefficiencies and overlooked details. Here is an easy and quick methodology that should help you identify these hidden cost drivers before they become excessively problematic.

• Begin with your open indemnity claims that have been active for more than 90 days. In that most injuries are orthopedic in nature, and normally that all bones heal, most often these soft tissue injuries and bony abnormalities resolved within 6-8 weeks. Are there significant co-morbidities such as tobacco consumption or diabetes? As such, those files open more than 90 days represent your highest exposure and greatest opportunity for intervention. When conducting your review, look at three areas: treatment patterns, return-to-work efforts, and administrative efficiency.

• Pull the medical bill history and look for fragmented care. Multiple providers treating the same body part (visiting the occupational medicine clinic every week as well as the orthopedic clinic every three weeks) without any significant improvement in the overall clinical situation or a decrease in symptomology. This fragmentation does not just inflate medical costs; it extends disability duration and delays reaching a maximum medical improvement determination. If the pain complaints continue to be 7/10, there needs to be a competent clinical explanation as to why. A Physician Peer Review may be helpful.

• The most expensive word in workers’ compensation is “later.” Review your indemnity files for documentation of transitional duty offers. If your file notes show “waiting for doctor’s release” or other verbiage without corresponding medical evidence as to why, you have found a cost driver.

Check whether work status is being actively managed or passively accepted. A competent clinical explanation supporting the determination needs to be identified.

Hidden costs often accumulate through poor administrative practices. Look for missing or incomplete medical records that slow decision-making, and other administrative tasks that slow claim activity. These inefficiencies do not just cost money directly; they prevent you from making informed decisions about case resolution.

Once you have identified files with these hidden cost drivers, prioritize them using a simple scoring system: one point for each red flag identified. Files scoring three or more points need immediate intervention, comprehensive physician peer review, or other cost containment tools. The key to this review methodology is speed and repeatability. You are not conducting a comprehensive file review; you are screening specific indicators that research and experience have proven several items to be significant cost drivers. By systematically identifying and addressing these patterns, you can prevent minor issues from becoming major losses while focusing on your case management resources where they will have the greatest impact.

Why Evidence-Based Medicine Reports Are Essential in Workers’ Compensation Claims

In the complex ecosystem of workers’ compensation healthcare, the relationship between clinical documentation and claims accuracy has never been more critical. Claims professionals now rely heavily on evidence-based medicine, skilled physician reviewers, and well-supported clinical citations to ensure that every claim reflects true medical necessity. These tools help safeguard injured employees, reduce inappropriate care, and protect organizations from costly errors or compliance risks.

Establishing a Strong Foundation

Effective peer review begins with selecting highly qualified reviewers who maintain current clinical expertise in their specialty. Organizations should develop consistent criteria for reviewer selection, ensuring standardized evaluation, reliable assessments of medical necessity, and alignment between documented findings and recommended interventions. National accrediting bodies increasingly emphasize this standardization as a best practice.

This is more than an administrative requirement—it is a clinical safeguard. Proper reviewer selection ensures that care is directly related to the compensable injury and that injured employees are not exposed to excessive, unsupported, or inappropriate treatment.

The Review Process

The review process starts with collecting all relevant medical documentation. Comprehensive records allow reviewers to accurately evaluate the injury, the treatment provided, and any future interventions proposed.

Peer reviewers should also assess the completeness of documentation. Missing progress notes, imaging studies, procedure reports, evidence-based medicine documentation, or other key elements can undermine clinical decision-making and lead to claim denials or audit findings. Identifying these gaps early allows for timely correction before claim submission.

Objectivity is essential. Clear, evidence-based statements grounded in recognized guidelines (such as ODG, ACOEM, and MDGuidelines) ensure consistency and accuracy. Subjective opinions, unsupported assertions, or ambiguous language introduce risk and weaken the clinical justification of a claim.

Conclusion

Peer review serves as a critical quality-control mechanism that bridges clinical practice and claims accuracy. By establishing clear standards, ensuring reviewer expertise, and fostering a culture of continuous improvement, organizations can produce claims that are clinically valid, thoroughly documented, and defensible. This approach not only protects organizational integrity but also supports the delivery of high-quality, medically appropriate patient care.

When a claim lands on your desk, intuition is not enough. In today’s complex workers’ comp ecosystem, defensible decisions require evidence, not opinion. As medical treatment grows more complex and costs continue to rise, Evidence-Based Medicine (EBM) reports have become one of the most valuable tools for achieving timely, fair, medically defensible, and well-supported claim decisions.

No longer would the axiom “because I said so” be employed as the standard. It is incumbent on all parties to outline the competent, objective, and independently confirmable medical basis to serve as the rationale for the determinations made.

At its core, EBM provides a structured approach to evaluating medical necessity by grounding clinical opinions in the best available research. For claims professionals, this creates a bridge between the often-ambiguous world of treating provider recommendations and the practical need to determine which treatments are reasonable, necessary, and causally related to the workplace injury.

Bringing Clinical Clarity to Causation and Mechanism of Injury

One of the first questions in a claim is whether the reported mechanism of injury can plausibly result in the diagnosis being treated. EBM reports help claims professionals move beyond subjective narratives to a fact-based assessment. When a board-certified physician or other clinician uses peer-reviewed literature to explain, for example, why a minor lifting event is unlikely to acutely generate a multi-level disc herniation, the adjuster gains authoritative clarity anchored in accepted medical science—not personal opinion or preference.

This clarity is powerful. It allows adjusters to make confident compensability decisions early in the process, preventing claims from drifting into unnecessary treatment or prolonged litigation.

Strengthening Utilization Review and Treatment Decisions

Treatment decisions can be especially challenging when multiple specialists make conflicting recommendations. EBM reports offer a consistent reference point by comparing proposed interventions to established guidelines such as the Official Disability Guidelines, the American College of Occupational and Environmental Medicine (ACOEM), or other medical society standards.

Instead of relying on anecdotal experience, adjusters receive a structured analysis of:

• Whether the diagnosis is supported by objective findings
• Whether the treatment aligns with guideline-supported care
• Whether alternatives may be safer, more effective, or more appropriate

This not only standardizes claim handling but also reduces friction between stakeholders. When treatment is either delayed or denied in the utilization review process, these non-certifications can lead to friction between the injured individual and the adjudicator. Applying EBM reasoning is transparent, clinically sound, and well-documented—something that the injured employee, the treating providers, and their legal representatives will recognize as credible.

Reducing Claim Duration and Medical Spend

Evidence-based peer reviews consistently shorten claim duration by eliminating unnecessary or non-causally related treatment early. They also prevent “diagnosis creep,” where new complaints or unrelated conditions become mistakenly attributed to the original injury.

By keeping the clinical record aligned with objective evidence, EBM reports reduce unnecessary imaging, limit unwarranted surgical referrals, and help focus care on recovery-driven interventions. Over the life of a claim, this leads to faster return-to-work timelines, fewer disputes, and significant reductions in medical spending.

Enhancing Defensibility and Documentation

Claims that do proceed to mediation or litigation benefit tremendously from a well-constructed EBM report. They provide a defensible medical rationale that supports the adjuster’s position and demonstrates diligence, clear objectivity, and adherence to industry standards. When a physician reviewer clearly cites literature, explains pathophysiology, and ties conclusions back to the specific facts of the case, it raises the credibility of the entire adjudication process. Make this standard apply in each report you request or use.

What Is Liberal Construction in Workers’ Compensation Law?

In any number of situations, a determination of the fine point is made, and we are wondering, “How the heck was that determination made?” A written statute, rule, or previous decision can fall victim to the nuances of the English language. Dating back to 1928, the legal concept of liberal construction was coined. Liberal construction allows many state statutes, particularly workers’ compensation laws, to be construed in a fashion that favors the injured employee.

Why the Law Leans Toward the Injured Worker

It is clear that by participating in the workers’ compensation system, the injured employee forgoes certain protections under other aspects of the revised statutes. To compensate for these “losses,” the concept of liberal construction is to be applied to protect the interests of the injured employee. This allows for inexpensive meaning in terms of provisions and other aspects of the statute. Understanding that the goal of liberal construction is to allow for the full possible effect of implementing the statute’s requirements and noting that not every type of situation can be imagined before writing the statute, this loose (or expansive) interpretation of the statute assists the injured worker in any way reasonably possible.

How Courts Apply Liberal Construction to Gray Areas and Ambiguities

Workers’ Compensation laws are designed to benefit injured employees. Therefore, by liberally construing the intent of the statute in favor of the injured employee, all possible protection is afforded. In this particular scenario, certain facts associated with the case may be considered by the judge, who can take these tangential factors into account when making the determination. Liberal construction does not eliminate the need for evidence of injury or causation. Instead, when statutory language is ambiguous, courts resolve doubt in favor of coverage—even when the facts present a close call or fall into a gray area not explicitly addressed by the statute.

Legal Backing: Section 312.006 and the Texas Supreme Court

This idea of liberal construction has become such a hot button that the government code was revised (section 312.006) outlining that “the revised statutes are the law of this state and shall be liberally construed to achieve their purpose and to promote justice.” It is specifically noted that the common-law rule requiring strict construction does not apply to the revised statutes. Furthermore, the Texas Supreme Court has noted that this doctrine must be decided in favor of the injured employee when there is a question of application.

Real-Life Impact: What Close Calls Mean for Injured Workers

If you have ever played Little League baseball, you have heard that ties go to the runner. However, under this concept, it is not only the ties that go to the injured employee, but close calls are also to fall in their favor.

Perhaps a better understanding of the concept of liberal construction will assist you in understanding some of the decisions reached in the workers’ compensation system. And I want to emphasize that perhaps it is the operative verb.

I have always been a visual learner. Watching how to conduct a specific procedure was much easier for me than reading about it. I have taken on this challenge of producing a written blog on a weekly basis, attempting to elevate the skill set of those who consume this material. I have come to learn that writing is so much more difficult than speaking. When we speak, there are facial cues, tone inflections, and other indicators of our true intent. Not so much with writing.

Frequently, when reviewing clinical records in preparation of the reports my team puts out, I see progress notes that really reflect the frustration on the part of the injured individuals relative to the administrative aspect of their Worker’s Compensation claim. I know that throughout our entire ecosystem each of us has become increasingly reliant on emails, text messages, and in a lessening perspective telephone conversation. We are all way too busy to take the time to meaningfully engage with that injured individual.

Technology boosts efficiency but introduces challenges, especially since visual cues are lacking in written communication. How can empathy and genuine care be shown to an injured employee through text alone?

Take a moment to reflect that the claimant navigating the complexities of the workers compensation system, tempered by the stress of the injury and the prodding offered by well-meaning family or friends and legal representation.

The Challenge of Tone in Written Communication

It is my nature to offer a joke or a mood-lightning quip to elevate the emotional state to a happier place. When people smile, chuckle or outright laugh the overall sense of well-being escalates and the point being made is more successfully received. However, doing this with an email, or text message, is particularly challenging. The words on that screen lack the warmth of a compassionate facial expression, the smile or grin, or the appropriate facial response when explaining the limitations of the workers compensation statute.

A straightforward message intended to be efficient can be perceived as cold or dismissive. The injured individual, already vulnerable due to injury and financial uncertainty, may interpret neutral language as indifference to their suffering.

In preparing this blog, I came across an article talking about communication psychology. This study suggested that 55 % of emotional meaning comes from facial expressions alone. An additional 38% from the tone of the voice. Given that digital text forms of communication can be challenging to read or interpret, there is a huge opportunity for misinterpretation on the part of the recipient. The fact of the matter is that a straightforward explanation can easily be misinterpreted as an individual claim file handler placing unnecessary bureaucratic needs in front of the requirements of the injured employee.

Strategies for Bridging the Emotional Gap

Where would I be if I did not attempt to provide solutions to these challenging situations? Workers’ compensation claims professionals can take deliberate steps to convey empathy and care in non-visual communication. These steps would include:

1. In written communication, begin with acknowledging the person’s situation:

“I hope your recovery is progressing well” or “I understand this process can be overwhelming.” Use their name frequently. Explain not just what you need, but why, and how it provides for that injured employee. Always offer reassurance and options for availability.

2. In phone conversations, verbalize what would normally be visual cues.

Be as careful as possible, reference and enjoyable event, demonstrate that you are providing your professional expertise for the betterment of that injured individual such as “I am reviewing your file now” or “I understand the difficulty that you are facing.” At the end of the conversation summarize all that has transpired, demonstrate encouragement, and follow-up on any tasks outlined. And be prompt which will demonstrate to the injured individual your commitment.

The Human Element in a Digital Age

An interesting article I read in preparing this blog, talks about digital efficiency and the need for being vigilant about the human cost of convenience. Every act of communication is an opportunity to increase trust between the claim file handler and the injured employee. One must continue to compensate for the absence of visual cues. Make sure that injured employee feels that they are being seen, heard, and those acute issues are being addressed. As part of this communication, that injured employees must be felt that they are valued in the entirety of the Worker’s Compensation process.

Experience and Perspective in Workers’ Compensation

For the record, I have been providing cost-containment services to the workers compensation ecosystem for more than 30 years. At times, I must admit that my serum cynicism level is off the charts. But then again, I get to see those cases that have become problematic and that most of the files being straightforward people seeking straightforward answers to the compensable injuries sustained.

The Misconception About Injured Workers

There is an all-too-common misconception that shadows any conversation about the nature of Worker’s Compensation. That is, the idea that injured workers do not want to recover. The idea that these individuals are content to stay sidelined and collect any indemnity benefits for as long as possible. Any participant in the workers’ compensation ecosystem will have stories that support this misconception, but these are often isolated incidences that are not only unfair but are fundamentally wrong.

The Reality: Most People Want to Heal

It has been shown that the majority of injured employees want to get better, get back to their lives, take care of their families, and provide. These injured individuals want to continue their independence and live a good life. In my experience, the issue is that system participants on both sides of the table do not know how to navigate the path to recovery.

The Overwhelming System

When someone is injured on the job, they are forced into a whirling ecosystem of medical appointments, insurance claims, legal terminology, being pursued by attorneys, a number of professionals assisting in the rehabilitation, and this can be quite overwhelming. Beyond this swirl, injured employees face issues with physical limitations, pain complaints, complex medical jargon, and a workers’ compensation system that varies from state to state. More often than not, there is conflicting advice from different healthcare providers as to how best to pursue the injury sustained.

Beyond that, pressure from employers, insurance carriers, attorneys, and the “advice” from family members or the guy next door only adds to the overall confusion.

Providing a Roadmap to Recovery

To help injured workers navigate this maze, we must provide them with a clear roadmap to recovery. Use your knowledge, your expertise, and provide waypoints on that map. A frequent example I use is that you could have a brand-new car, drive it off the lot, and strike a tree. Irrespective of how good the body shop and mechanics are, it will never be a “brand-new car” again.

Understanding Change and Healing

Similarly, when someone gets injured, their anatomy is not the original equipment they had 10 minutes prior to the event. The body heals; however, there are potential complications or negative sequelae that could occur. That injured individual needs to understand that a significant change in their normal life path has occurred, and this must be dealt with. All parties need to understand that there are comorbidities that are unrelated to the compensable event but can be problematic. Issues with these types of changes in the health of the injured employee can result in mental health diagnoses such as depression.

The Role of Education and Empowerment

Additionally, it is incumbent upon all those interfacing with the injured individual to inform them of the type of information they need to obtain in order to accomplish their goal of recovery. Helping these individuals understand what questions to ask their doctors, what their rights and responsibilities are within the workers’ compensation system, and what is appropriate treatment for the actual injury sustained. These individuals need to be encouraged to participate in their own recovery. This does not mean pushing one’s limits, only that the medical determinations made should be trusted and referenced, enabling them to obtain all care appropriate for the injury sustained.

Communication, Support, and Accountability

By delivering these educational items as noted above, this empowers the injured employee with the education and knowledge they need to engage in their rehabilitation, outline how to communicate more effectively with healthcare providers and others tangential to the injury, and how they can best control and participate in the recovery. With this knowledge, and every item completely answered, it will enable the injured employee to return to work more successfully. Showing your support in all aspects of the claim file significantly contributes to the overall positive outcome. Be accountable to everyone in the process.

Bridging the Knowledge Gap

In summary, what the injured employee needs is clear, frequent, and appropriate communication in plain language that all parties understand. Establish a clear path enabling them to navigate the system successfully. As a dear friend once said, all workers’ compensation is the same; however, it is different in every state.

Irrespective of your particular role in the workers’ compensation ecosystem, keep at the forefront of your thought process that the person you are assisting most certainly wants to get better. All too often, I see that the limitations are a function of education, and that injured employees not having all the pertinent data necessary compromises the outcome.

Thus, it becomes our mission to bridge that knowledge gap, provide guidance, enable navigation, and get this individual back to health, in as timely a manner as possible, returning the injured worker to maximum productivity. These injured individuals need to be approached with empathy, education, and the idea that while accidents are bound to happen, the results can easily be overcome.

Understanding the Misuse of the Term “Concussion”

What a great question, if I do say so myself. In my more than three decades of providing cost-containment services from a clinical perspective to those Worker’s Compensation professionals, one frustration is that each time somebody takes a slight (or minor) impact to the head, this is described as a “concussion.” In our Worker’s Compensation ecosystem concussion has become synonymous with any head injury. In reality, this is far from the truth, with respect to head injuries.

The Body’s Built-In Protection for the Brain

The human body is a terrific machine. There are a number of built-in protections for various functions. What can be more important than protecting the neurologic engine that drives everything? Anatomically speaking the brain is housed within the skull and just look how thick the skull actually is. Surrounding the brain within the parameters of the skull is cerebral spinal fluid designed to protect and preserve brain function. Beyond that, the brain is not overly fragile, this is not to say it cannot become damaged or injured, only that the forces necessary to compromise the brain are significant. Typically, a blunt force trauma that does not result in visible injuries such as abrasions, is unlikely to cause a mild traumatic brain injury (mTBI).

What Defines a Concussion (mTBI)?

Specifically, a “concussion” is a mild traumatic brain injury (mTBI) and this is characterized by temporary neurologic dysfunction. Unfortunately, this type of injury is not visible with the standard enhanced imaging studies. This is why ambulance attendants will ask;

1. “Did you hit your head?” or
2. “Did you lose consciousness?” or
3. Were there other identified findings?

These questions are repeated during the course of the emergency room evaluation conducted evaluating the identified injury.

Diagnostic Criteria for a True Concussion

According to the American Congress of Rehabilitation Medicine (1993), a concussion involves an altered mental state at the time of injury, possible loss of consciousness, and post-traumatic amnesia lasting less than 24 hours.  Consequently, if an individual has a slip and fall and specifically notes no head injury, no evidence of loss of consciousness, or issues with amnesia, then this would exclude a diagnosis of concussion or mTBI.

In the situation where there is a scalp laceration or contusion, given the vascularity of this structure, significant bleeding is identified. While appearing to the lay person injured, this might seem severe, from a clinical medical perspective if there is no specific neurologic dysfunction, there is no objectification of a concussion.

Even with some types of skull fracture, such as linear fractures, it is not always clear that an injury to the brain occurred. We are not saying that it did not occur, only that the needs to be a competent clinical discussion/assessment prior to making the diagnosis of concussion.

When Imaging Reveals a More Serious Injury

If imaging studies identify an epidural or subdural hematoma, these findings indicate a significant and potentially life-threatening injury. These conditions are distinct from concussions and demand urgent medical attention.

Recovery and Frequency of Concussions

Most concussions resolve within days or weeks, while more severe brain injuries may require extended rehabilitation and can lead to lasting cognitive deficits (McCrory et al., 2017). True concussions do occur but are less common than often assumed within the Workers’ Compensation community.

Evaluating Concussion Claims Accurately

When reviewing a claim involving a concussion diagnosis, it’s essential to examine the specific ICD-10 code (S06.0X0), imaging results, Glasgow Coma Scale scores, and neuropsychological test findings. Remember: not every bump to the head constitutes an mTBI.

Confirm Clinical Evidence Before Accepting the Diagnosis

Never take a concussion diagnosis at face value. Independent confirmation of key clinical indicators—loss of consciousness, altered mental state, or post-traumatic amnesia—is vital. Ensuring diagnostic accuracy supports proper claims management and upholds medical integrity within the Workers’ Compensation system.

For those interested in further reading, there are several citations I would suggest you take a peek at:

• Bullock, M. R., et al. (2006). Surgical management of acute subdural hematomas. Neurosurgery, 58(3), S16-S24.
• Haydel, M. J., et al. (2000). Indications for computed tomography in patients with minor head injury. New England Journal of Medicine, 343(2), 100-105.
• Maas, A. I., et al. (2008). Moderate and severe traumatic brain injury in adults. Lancet Neurology, 7(8), 728-741.
• McCrory, P., et al. (2017). Consensus statement on concussion in sport—the 5th international conference. British Journal of Sports Medicine, 51(11), 838-847.
• Mild Traumatic Brain Injury Committee. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(3), 86-87.

Show Me the Money: The Core Truth of Workers’ Compensation

In the world of Worker’s Compensation, there is one absolute truth; and to quote from Jerry Maguire, “show me the money.” Those who have been reading my blog understand that it is my position that all appropriate care should be delivered to the injured employee. You as the claim file handler need to be an advocate for the injured employee. However, it is clear that there are several evolving tangents that each individual claim file handler must deal with when attempting to resolve the claim.

The Challenge of Unscrupulous Medical Providers

There is one component of our little sandbox that is particularly onerous—and that is the unscrupulous medical provider. There are those who believe that insurance companies have the deepest pockets, and they can abuse the system with billing practices, up-coding, reporting services while billing for same without providing those services, and any other number of untoward schemes.

The frontline in defense against those underhanded practices is the Workers’ Compensation claim file handlers. These claims professionals should recognize these scandalous practices by those providers wishing to inflate their wallets, as opposed to providing all care reasonably required to address the actual sequelae of the compensable event.

Recognizing Red Flags in Questionable Medical Practices

The first step is to recognize the “red flags” that indicate questionable medical practices. This would include:

• Excessive frequency of visits (Does that sprained ankle need to be evaluated every three days?).
• Requests for unnecessary testing when physical findings do not support the need.
• Overreliance on passive treatments, such as excessive physical therapy, modalities, or chiropractic adjustments.
• Unnecessary work restrictions that may encourage less-than-candid behavior from the injured individual.

When Pre-Existing Conditions Are Misrepresented

Not all of these less-than-upfront efforts are geared solely to making money. Sometimes, in an attempt to assist the injured individual, certain declarations are made that try to tie pre-existing pathology to the reported compensable event.

For example, reporting a macerated, complex tear of the medial meniscus as an acute tear when there are no markers of acute injury identified in diagnostic imaging is unfair to all system participants. Worker’s Compensation costs eventually reach all consumers through increased prices of goods and services.

Building a Defense: Use Your Entire Team

How do we address this deceitful presentation? Use your entire team—including Nurse Case Managers, Defense Counsel, Utilization Review companies, and cost containment experts.

A good first step is ensuring that all providers are fully licensed within your jurisdiction, in good standing with their state medical boards or professional agencies, and maintain an honest reputation. Checking your state medical board’s website for sanctions or disciplinary actions is an excellent practice.

Scrutinizing Billing and Treatment Practices

The next step is to scrutinize billing practices. Use all available services to ensure appropriateness and accuracy. Look for signs of:

• Overbilling or up-coding
• Simple procedures described as complex to justify higher charges

When reviewing treatment plans, refer to established parameters such as those reported in the Official Disability Guidelines®. Verify that treatments are supported by utilization review and clinically indicated—and that they are tied directly to the compensable injury.

Establishing Trusted Provider Networks

Where possible, develop a network of trusted providers or referral sources who can provide comprehensive, independent clinical assessments. These assessments help clarify best practices and ensure injured employees receive the care they truly need.

Reporting Fraudulent or Inappropriate Behavior

If you suspect fraudulent or inappropriate behavior, report those providers to your state Worker’s Compensation system for investigation. Removing unethical actors strengthens the system for everyone.

Protecting the Injured Worker

It is your professional responsibility to protect injured workers from deceptive providers. Some employees may not be informed or may simply trust anyone wearing a white lab coat. If you recognize questionable behavior in your files, act promptly to transfer the injured employee to a compliant, ethical provider.

The Skills Every Claim Adjuster Must Master

Dealing with unscrupulous medical providers requires a specific set of skills for every claim adjuster—vigilance, knowledge, and strategic action planning. By maintaining the highest ethical standards, you ensure that every injured employee receives the care they need, as quickly as possible, with the best possible outcome.

The Growing Concern: PTSD in Worker’s Compensation Claims

A diagnosis that is occurring with increasing frequency is post-traumatic stress disorder, a.k.a. PTSD. This specific diagnosis is a mental health malady that has very specific criterion before it should be applied in every scenario. The media has outlined a modification to the standards, and several state jurisdictions have expanded the definition with particular attention to “first responders” and this becomes a critical concern for claim file handlers in the Worker’s Compensation scenario.

What Defines a Traumatic Event? Understanding the First Criterion

The first criterion is that the “injured individual” has been exposed to or witnessed a traumatic event. There is specific criterion identified in the DSM-5 that should be applied whenever there is a suggested diagnosis of PTSD.

To be clear, two separate individuals participating in the same situation could have vastly different responses to that identified event. The first criterion is that there must be exposure to a specific traumatic event. The next question becomes what is a trauma? Some authors suggest this is a deeply distressing or disturbing event, or a series of events, and that this event(s) overwhelms an individual’s ability to cope. These scenarios are mostly thought of as a life-threatening situation, a compromise to personal safety or integrity. The applications of this particular criterion have grown. However, in the scenario of PTSD, there needs to be clear clinical evidence of significant psychological response, physiological response, and emotional response to the noted stressor.

Others believe the events need to be outside the normal course of human experience. Clearly combat exposure, sexual assault are outside this norm. How does one establish a natural disaster as being outside the normal course? There will be fires, there will be rain and floods, and all sorts of natural phenomenon. Understanding the definitions noted in the medical literature, one has some difficulty correlating the two.

The DSM-5 Criteria: Key Symptoms for a PTSD Diagnosis

The next criterion is classified as intrusive symptoms. Often recurrent, involuntary, and specific sequelae such as nightmares occur with this diagnosis. The psychological distress results in an intensive scenario that compromises ordinary daily activities. The DSM-5 requires at least one of these intrusive symptoms to be present prior to making this diagnosis.

Next would be the objectification of avoidance behaviors, alterations in mood, and cognition. Individuals with this diagnosis experience significant negative alterations in their patterns and mood. In some situations, there is a marked change in arousal and reactivity resulting in irritable behavior, aggressive anger outbursts, or self-destructive behavior. Again, noting the DSM 5 standards to arousal symptoms must be present prior to making this diagnosis.

Beyond that, several additional findings must be identified. The symptoms must be present for more than a month, the need to be significant compromise to social or occupational scenarios, and these findings cannot be attributed to any other clinical situation.

Conclusion

The point is, this is a truly traumatic diagnosis, unfortunately this diagnosis gets assigned inappropriately or prematurely, particularly in the Worker’s Compensation scenario. Not everyone who witnesses a motor vehicle collision should be considered with a diagnosis of posttraumatic stress disorder.

The standards as outlined in the DSM 5 need to be the checklist utilized in the standards to be met then independently reviewed and endorsed prior to making this clinical assessment. The unfortunate aspect is that this particular diagnosis often times never resolves and the injured individual who sustains such a significant mental health injury can require extended if not lifetime treatment. Please ensure that all appropriate steps and safeguards are taken prior to accepting this diagnosis so that the most appropriate treatment can be delivered where necessary.

As seasoned Worker’s Compensation professionals, and even for those of you who have just joined our little party, you are all aware of the crucial role you play in effectively managing claims, ensuring fairness to all parties concerned, and each of the identified stakeholders. It has been my experience, as someone who has run a cost containment concern for the Worker’s Compensation ecosystem for more than three decades, those who master the use of the cost containment tools available to them do not just survive, they absolutely thrive in terms of establishing their level of professionalism, completing each of their assigned tasks, and closing out the claim file.

One of the key strategies that all members of our ecosystem must employ is the strategic utilization of all cost-containment tools and maximizing the efficacy of this intervention. To accomplish this, one must start with an understanding of all those tools that are available. Obtaining clarity of the compensable injury from a clinical perspective, with the application of evidence-based medicine principles, enables you to make informed decisions at the right time with the best possible outcome.

Start with Early Intervention

The “Golden Hours” of any workplace injury occur as quickly as possible after the identified event. Obtaining the applicable clinical information as soon as possible tends to be more accurate. If the noted injury is suspected to be particularly serious, have a nurse case manager intervene in this case as quickly as possible.

Obtaining all appropriate clinical information as soon as possible will contribute to the best possible outcome in the claim file experience. Those successful claim file handlers clearly understand the benefit of immediate engagement with the injured individual.

Therefore, combining the nurse case manager intervention with prompt medical assessment and conversation with the injured employee contributes to the best possible outcome. Those specific tools available include an Early Compensability Assessment or Peer Review. Understanding the extent of the compensable injury, to an evidence-based medicine determination level, will dramatically influence the outcome of the identified injury.

A question to ask yourself: “How can I apply early intervention in my current cases?” Taking a peek at your newer files could only benefit and reduce your file count.

Master the Art of Clinical Peer Review

Understand that clinical peer reviews, particularly those who rely upon the standards of evidence-based medicine, are potent weapons in terms of delivering all appropriate care to the injured individual, providing only the care that is necessary to address the sequelae of the compensable injury, and this precipitates as rapid a resolution to the injury sustained as clinically possible.

When using these tools, examine the issues to be addressed and modify the templated questions to reflect the particular clinical situation as you understand it. Not every question is applicable in every clinical situation. Therefore, to obtain the most efficacious report, have that review target the specific areas where you have a concern.

Remember, each of these identified cost-containment vehicles are a specific investment that frequently pays dividends many times more than their relative expense. An additional benefit is that when you communicate the findings identified in the peer review with the injured employee and explain the rationale behind the determinations, this lessens the friction or contention between the injured individual and the carrier. This reduced friction will mitigate future expenses.

And do not forget to communicate with the employer, as they may offer insight not readily apparent in the records/documents presented for review. This additional engagement and conversation should focus on any possible return-to-work programs, with a meaningful protocol that enables and maintains a significant reduction in claim costs.

Conclusion

• Effective cost-containment is not about cutting corners; it represents a professional, intelligent, and strategic claim management scenario that benefits all parties concerned.
• Maximizing these tools does require an understanding and implementation of proactive management strategies.
• With the appropriate implementation, each claim file handler will achieve superior outcomes and build their personal brand as a trusted professional in completing their individual responsibilities.
• Early active intervention and clinical assessment are paramount in claim file handling
• This early and comprehensive clinical intervention will serve to benefit all those tangentially involved in the identified claim.