In every encounter in our practice within our Worker’s Compensation ecosystem, each interaction is modified by our personal experience. During my career pursuing cost-containment measures within Worker’s Compensation, two of the most dreaded words were “lumbar fusion.” The issues related to lumbar fusion often included persistent pain, long-term disability, and significant changes to the lifestyle of the affected employee.

Personally, I have a long history of chronic low back pain, beginning with my tenure working overseas for Uncle Sam. First Sergeant O’Brien felt it was a good idea for me to jump out of a hovering helicopter with my rucksack and aid bag, leading to my first insult to healthy normal lumbar anatomy. Subsequent multiple lumbar injuries occurred while wearing the uniform, and throughout the rest of my adult life, with several additional comorbidities.

It came to a point where I could not pass what I call the “early morning test.” That is to say, which hurt worse –my full bladder or my low back pain? I visited an incredibly good friend/orthopedic surgeon who sent me for MRI/CT scan. When the studies came back, he texted, “Dude, really?”

There were significant degenerative changes, and I developed a condition called DISH, a condition where ligaments turn into bone. My entire lumbar spine and thoracic spine had fused, except for two levels. Given the ongoing symptomology, the only realistic treatment option was to tolerate the pain or undergo, you guessed it, lumbar fusion surgery.

I am sharing this not as a medical case study, but because it fundamentally changed how I evaluate post-fusion complaints, disability duration, and credibility in workers’ compensation claims.

As a PA in orthopedic surgery, I have taken part in this procedure many times. I must tell you that lying down on the hospital gurney and looking up at those surgical masks, is a far dissimilar experience than being the guy standing over that patient going into the OR. Somehow, I remembered a book I read during my training, Physician Under the Knife. It was a surgeon whose perspective changed after undergoing surgery.

After my 4:30 AM arrival at the hospital and undergoing all the routine preoperative protocols, my memory was that after being wheeled into the spine surgery OR suite, the room was flipping cold! I mentioned that to the anesthesiologist, who reiterated my complaint. That was the last thing I remember. The utility of the newer anesthesia medications is spectacular. I had no memory after my complaint about the environment until I awoke in my hospital room some eight hours later. It took that long to complete a four-level fusion and to successfully recover from anesthesia.

While there was some post-operative discomfort, candidly, it did not hurt all that much. While following a preemptive analgesic protocol, the biggest challenge I encountered, other than the hospital food, was finding a comfortable position that kept my spine as straight as possible. I returned home after spending two days in the hospital. Continuing with the same protocol, I did well. On postoperative day four, I successfully discontinued administration of opioid analgesics and stopped the muscle relaxant regimen. Approximately one week later, the lumbar brace was applied and I continued to improve.

Since I work mostly from home, I resumed modified duties five days after surgery. One of my clients, a skilled worker’s compensation attorney, was astonished that an individual who underwent a four-level thoracolumbar (T11-L3) fusion was back at work on that fifth day.

I have been thinking about this reality of post-fusion protocols, with some increased clarity. Candidly, I am not sure why I had such an exceptional outcome, but it was my personal belief system that this surgery was not going to slow me down.

Another project I worked on with Mark Pew, Bob Wilson, and Melissa Steger is WorkCompCollege.com WRP training. This training enables Worker’s Compensation professionals to look at that injured employee not just from the pathological perspective but from the whole-person perspective. What motivates that injured employee, what issues are compromising the response, and other noted entities. While noting my medical background and personal experience dealing with injured employees undergoing this type of surgery, these are several of the biopsychosocial factors that all comp professionals need to incorporate into their decision-making.

In my case, my sole frustration was that I could not return to work as quickly as I had hoped. Going forward, when I am dealing with a case where there was a lumbar fusion, there is insight into what specific factors are driving the current complaints. Given my response, careful questioning as to the objective basis for the ongoing complaints will be the standard. And I can honestly say, yes, I have experienced all that you are experiencing.

The main idea is that each case is different. Not all reports of back pain following fusion surgery are justified, unless there is a clear clinical reason. Look at the entirety of the claim, the 360° perspective of the injured individual, and proceed as appropriate. It is quite possible that exceptional results can occur after a particularly gnarly clinical situation. Our goal should not be to fear the fusion; it should be to identify the factors—like motivation, support, and clear communication—that turn a ‘dreaded’ surgery into a success story.

As a workers’ compensation professional, one of the ongoing challenges is assessing whether the recommended interventions are clinically appropriate, medically necessary, and will genuinely help the injured person return to work with maximum medical improvement. Certain decisions are entirely suitable for the requested treatment. A slip and fall in a 63-year-old individual resulting in a comminuted fracture of the femoral head clearly requires surgical intervention to include total hip replacement arthroplasty.

However, some requests or interventions are questionable. While understanding there is a clinical indication for a total hip arthroplasty in the case noted above, there is no indication for whole-person massage therapy every other day for the next six weeks.

In the past, there was a traditional reliance on intuition or anecdotal experience. With the implementation of the standards of evidence-based medicine (EBM), this is no longer a sufficient basis to endorse any intervention. Instead of applying the standard of “this is how we’ve always done it” it now becomes secondary to the identified citations; this is best practice for this clinical situation.

The clear solution is to apply EBM standards to the determinations that are being made. The utilization of evidence-based medicine is not about denying care or cutting corners; it is about applying the most recent and best scientific evidence to support the request. When a provider uses research-backed guidelines and recommends treatment supported by these clinical studies or established protocols, you can confidently approve the request. However, when the request falls outside these accepted standards, there is a clear objective basis to question the noted intervention.

Additionally, the application of evidence-based medicine starts with the determination of the extent of injury as a function of the reported mechanism of injury. The evidence-based medicine process is straightforward: note the symptoms, identify the findings on objective diagnostic imaging studies or other clinical data, and boil this down to the lowest common denominator. This is where the diagnosis relative to the compensable injury lies.

Subsequent applications relative to clinical questions advance the determination from a subjective judgment call to a transparent, medically defensible process that serves the interests of all parties concerned.

It is no secret that healthcare costs continue to rise. However, with the utilization of evidence-based medicine in the decision-making process, it is clear that over-treatment or unnecessary interventions will be mitigated. Not only will this minimize the length of the claim, but it will also accelerate recovery and alleviate any complications or other friction points noted.

Lastly, for all decision makers noted in the adjudication process, the application and utilization of this particular standard will be a career differentiator. Understanding and applying appropriate evidence-based medicine guidelines establishes you as that trusted advocate for the injured employee and your organization. Do it right the first time.

As a significant player in the workers’ compensation space, one of our most critical responsibilities is assembling a reliable network of vendor services. The quality of our vendor relationships directly impacts injured employee recovery, claim outcomes, and costs. Here’s how we’ve approached building this essential infrastructure.

Cataloging Medical Specialists

One of the key components are those individuals who provide physician peer reviews. Start by mapping the medical specialists most relevant to your claim portfolio. In workers’ compensation, certain specialties consistently emerge: orthopedic surgeons for musculoskeletal injuries, neurosurgeons for spinal and neurological cases, psychiatrists for psychological claims, and pain management specialists for chronic conditions. Don’t overlook physiatrists, hand surgeons, and occupational medicine physicians, either. They are invaluable for specific injury types.

Create a detailed database that goes beyond names and contact information. Document each specialist’s areas of sub-specialty, average turnaround times, geographic coverage, and fee structures. Track their willingness to accept workers’ compensation cases, as many specialists have limited availability for these patients. This living document becomes your roadmap when navigating complex claims.

Establishing a Physician Peer Review Panel

Physician peer review is where competent, authoritative medical opinion meets claim adjudication. Having the resource of a physician peer review panel delivering quality reports is critical. We have learned that not all peer reviewers are created equal. The most valuable reviewers provide specific, evidence-based (and citation-supported) responses that directly address the questions posed.

When vetting physician peer review providers, evaluate whether their reports cite current medical literature and treatment guidelines. Do they answer your specific questions about causation, maximum medical improvement, or treatment appropriateness? Are their opinions defensible and well-reasoned? Timeliness is essential and matters tremendously. A brilliant review delivered three weeks late loses much of its value.

Pricing should be competitive, but remember, the cheapest option often generates the most headaches. A thorough, well-documented review at a reasonable price point saves money by reducing disputes, depositions, and litigation costs. Build relationships with reviewers across multiple specialties who understand the administrative and legal framework of workers’ compensation.

Assembling Ancillary Service Providers

Beyond medical professionals, your vendor network should include nurse case managers who can coordinate care, attend medical appointments, and provide critical oversight. Quality nurse case managers bridge the gap between clinical care and claims administration, often identifying issues before they escalate.

Maintain relationships with legal resources, skilled defense counsel experienced in workers’ compensation, and Medicare Set-Aside professionals, where appropriate. Know who to call for surveillance services, vocational rehabilitation, or independent medical examinations.

The Bottom Line

Your vendor network is not just a spreadsheet; it is a strategic asset. Take time to assess your personal set of metrics. Are your vendors responsive? Do their services meet your administrative requirements? Are your outcomes improving?

Invest time in relationship-building. The vendors who understand your expectations and philosophy become true partners in claim resolution. In an industry where every claim presents unique challenges, having the right expert available at the right moment makes all the difference between efficient resolution and prolonged, expensive disputes.

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.