Monday, December 9, 2013

Delay Or Deny At Your Risk

There are so many reasons why both employers and workers feel that workers' compensation is "broken" or doesn't work.

Peter Rousmaniere, who is beginning work this week for WorkCompCentral, suggests in his column reviewing two studies on perceived delays in medical treatment that delay may arise as much from indifferent doctoring skills as days elapsing on the calendar. 

An employer consultant relayed to me a factual scenario indicating another cause of this perception - standard claims administration protocol, which is defensive in nature as opposed to being aggressively pro-active.

Rousmaniere cites a couple of studies in his column. A Texas Department of Workers' Compensation survey of injured workers documents wide discrepancy in perceptions, but also notes that up to 50% of all survey respondents complained of some delay in receipt of treatment.

Another study cited by Rousmaniere conducted by Harbor Health, which specializes in designing workers’ compensation provider networks, looked for differences in claims outcome, including medical cost and litigation rates, and if surgical treatment happened early or late in the course of treatment.

Harbor Health found that early surgery in carpal tunnel cases (earlier than recommended by treatment guidelines) produced slightly more cost in medical expense but much less cost in indemnity expense.

Let's put these findings into context.

Assume a 28 year old male worker who complains of "numbness, tingling and pain in both hands for the past year or so" and that "IW states that he thinks he has carpal tunnel syndrome."

First thing that is going to come to mind for most claims administrators is, "bull!" 28 and male do not fit the normal risk demographics for carpal tunnel syndrome, and the fact that the employee said he "thinks" that he has carpal tunnel suggests that he is looking for a claim.

However we don't KNOW that! All we know is that there is a worker with a complaint. The complaint is some physical symptom presentation that doesn't make biological, anatomical or medical sense.

But a claim was made.

Do you deny? Do you delay? Do you accept and just get the ball rolling?

What do YOU do?

My guess is that most of you would say issue a delay letter and begin investigation in order to protect your legal position.

Note that you are protecting your LEGAL position - not the employment position, not the social position, not the psychological position, not the medical position.

Immediately you have postured defensively.

What is this investigation going to cost you? In terms of actual out of pocket expense, in terms of ongoing liability for indemnity and disability, in terms of potential future medical expenses?

How about lost productivity on the factory floor, or damaged morale within employee ranks? What about over time for replacement workers?

Why gate-keep? Why engage in trying to deny rather than getting the worker immediately and without question to a doctor?

Yes, there is paper work to complete, and the normal three point contact needs to be initiated as well as the normal investigatory activities - but the immediate response should be to assist that employee file the claim, immediately get that employee to a doctor (the employer should facilitate that engagement), get human resources involved (if there is an HR department) to get more information about what is REALLY going on with this employee (as noted, the risk factors don't add up) and make sure that this employee KNOWS that his needs will be met.

Overboard? Taking on a claim for which there may ultimately be no liability?


But how often do denied claims really, really stay denied? The answer: Only until the worker gets himself to an attorney who knows how to work the system. And then claim costs really escalate.

The perception in delays with workers' compensation medical care is because we facilitate those delays by being on the defensive as soon as a workers says they aren't feeling good, or complain of some symptoms that they relate to their work.

The Texas and the Harbor Health studies cited by Rousmaniere suggest that we can control such perceptions by being aggressive in getting the claimant to a doctor RIGHT NOW, and just taking care of the claim.

If in fact there is industrial causation then the employer/administrator owns that claim and the earlier it is taken care of the cheaper it will be.

And if in fact there isn't industrial causation then at least the employee was shown by the employer that there is a caring attitude and the result should be a more engaged, happy employee on the line.

If that employee isn't happy, then there are other remedies for dealing with a less than satisfactory employee outside the workers' compensation system, and human resources has the tools for that.


  1. .
    Every workers compensation review I have taken part in over the years has always come back with changes to legislation, increase to monitoring and reductions to injured workers rights and benefits while the employers are left to carry to costs of poorly managed self-indulgent regulators.
    Whilst the workers compensation schemes here in Australia are run differently to the workers compensation schemes in America, the basic concepts remain the same.
    Some one pays for workers compensation.
    Some one goes to work and becomes an injured worker.
    Some one gets the claim.
    Some one(s) makes a good deal of money processing and churning the claims.

    The largest challenge I face every day is engaging each part of the process for the best outcome for each party.
    However in the larger scheme reviews still remain industry based, very few injured workers are ever "heard" simply because they are too fearful of the repercussions of telling their stories.
    My best suggestion if anyone is actually interested in finding out what is wrong and what needs to be changed, is to hold a summit of injured workers, and allow them the opportunity to speak without fear.
    I know what their stories are, I know what they will tell you and more importantly I know what needs to be altered.