Tag Archives: thompson

How to Avoid Work Comp ‘Fact-cidents’

Every workers’ compensation claim is not preventable, when you consider that some are deliberate. With due respect to the art and science of safety, preventing real physical accidents and repetitive traumas is essential. However, we also need to be mindful of and prepared for the non-accident accident. Let us refer to these situations as “fact-cidents” because their construct relies on the ability of a claimant to tell a credible story void of facts.

First of all, let’s establish fact-cident detection as an employer’s responsibility. An adjuster with the best list of “red flags” cannot match the gut instinct of an astute employer who knows an employee’s history and extraneous issues and has opportunity to look that employee in the eye. An unwitnessed fall out of a chair or a bump against a restroom-stall door, or a “giving out” of the knee when turning with a parts tray in hand can be very valid claims… until they are not, mainly because the employer knows something deeper about the employee’s motivation.

The employer must share concerns with the adjuster within the early hours or days of a claim to support heightened focus. Most fact-cidents cannot simply be denied. Very quick work is required. The good news is that fact-cident defense is time-consuming but not complicated. It simply involves obtaining multiple verifications of the story. Just like the old saying, “there is no such thing as the perfect crime,” there is also no such thing as the perfect false claim. Enough prodding will diminish credibility and isolate the fact-cident for the house of cards that it is.

Quick Tip: Ask, Ask Again and Ask Some More

An injured worker should be required to reiterate his story four to six times within the first 48 hours. Here is an optimal sequence:

– Report to supervisor, who writes down claimant’s account

– Call in to triage line, where a nurse interviews and records claimant’s detailed account

– Workers’ comp lead (WC or risk manager, HR, benefits, company nurse, etc.) requires discussion and writes down another reiteration of the incident

– Treating doctor requires a detailed reiteration of the incident as part of history

– Adjuster takes recorded statement of the claimant’s account

– Adjuster and employer-leaders separately circle back to claimant after doctor visit to get claimant’s version of the doctor’s assessment

With these multiple stories and queries, the true detective work begins in comparing and sharing claimant versions. Fact-cident claimants notoriously will assume what certain parties want to hear and adjust stories accordingly. They also may enhance their story gradually with each reiteration. After medical visits, they often alter what actually happened or was said by the doctor. Sadly enough, many seem to think they can play all sides to the middle with no cross-checking among the crowd. Don’t let that happen!

The investigative test relies on comparing all versions and then, as might be indicated, sharing with other parties. For example, if the initial supervisor and HR manager reports mention non-falling incident with ankle pain but the version to the doctor claims a fall to the floor adding hip, back and elbow pain, you have an immediate piece of evidence validating suspicions. You can confidently invest and engage denial, defense, independent medical exam (IME), surveillance, field nurse, et. al.

Inconsistencies can also be presented to the doctor for review and revision or re-exam to correct any false reliance on claimant’s story. If possible, with cooperative providers, the early internal reports can be shared with treating doctor in real time so she can diligently test the employee’s credibility against other statements.

An even more powerful reason to collect and solidify various versions is to avoid future attorney representation and fact-cident influencing. Worst-case scenario with lack of early employee statements is that an attorney gets to coach the employee into a tighter self-serving story later on.

When you suspect an accident is actually a fact-cident, don’t accept any aspect at face value. Put in the time to either confidently validate and pay the claim or justify heavy investments in defense.

As a bonus, from the big-picture perspective, this type of consistent diligence establishes a general no-nonsense workplace attitude and culture when it comes to workers compensation.

Electronic Health Records Hurt Care

Patient care as we know and expect it will diminish because of electronic health records (EHR) requirements. Society will suffer a slow degradation of artful interactive provider attention in deference to “data-field” medicine.

I am not simply referring to the very real and challenging issues in the technical application of EHR systems. Rather, I point out a more serious and insidious future threat to the actual human aura in medical practice.

There exists an unintended but real incentive for doctors and clinicians to consider task-completion as clicking through the data interface rather than interacting with and treating the patient. Legal requirements, reimbursements and potential penalties force EHR to top priority. In turn, clinicians as EHR users become more aware of and anticipate the truncated, template-driven and limited means of expressing case events via electronic reports. Therefore, their interaction with patients may be truncated.

I know this sounds callous and insulting to all good medical providers. To them, I say no insult is intended, and the fault of this perverse incentive is not theirs. They might honestly assess their experience and the actions of peers and associates within their practices given the advent of EHR. To providers, I ask: What about EHR might be sucking the creative life out of your optimal vision for the practice of your specialty?

My most stark encounter with this reality comes from a chance discussion with a longtime friend. She is a nurse practitioner who, for decades, has treated both ER and family-practice patients. As family friends, we never talk shop, and this particular conversation was not solicited by me. I politely asked, “How’s it going?” and got a surprising, soul-baring burst of frustration.

She expressed disdain. She prides herself as a master of triage, symptom investigation, on-the-spot research and communication with involved family members, and she desires to take the wide approach to patient situations as a service to them and to the doctors or specialists who may eventually carry the case, but electronic records don’t allow the narratives or collective points of data she would prefer. As such, her value is diminished, and the patient ultimately gets poor attention.

As she described her situation, I began to understand the rigid decision-tree “intelligence” in narrowing prompts for information based on how case records are initiated. She has persevered and found cumbersome work-around methods (such as editing previous fields to change next options, etc.) to combine or add issues or thoughts to a record beyond the template’s desired straight line of thought. Unfortunately, she explained, taking extra time to do anything is neither advisable nor encouraged because of the volume of patients requiring care.

Quick Tip: The Want for Data Should Not Put the Cart Before the Horse

As a foreshadowing about healthcare in general, consider what the supreme focus on automation and data collection has done to workers’ compensation. I have written extensively about the advent of electronic claim systems, over decades, reducing the adjusting job from that of an intelligent, intuitive personal-interactive specialist to the current task-level data entry clerk. We are now well into the post-paper-file generation of claim adjusters who know their job only as data-interface. Will medical clinicians meet the same fate when our current generation of providers, like my friend, move on? Will future clinicians, knowing only electronic records, assume that the decision tree of the EHR interface supersedes intuitive medicine?

Let’s hope not. Unfortunately, a simple Google search for “problems with EHR” will not sit well with anyone who embarks on some research in this area.

In claim adjusting, as in medicine, we need to intelligently feed the hunger for data but rail against a perverse desire to let automation increase case volumes or assume the template is sacrosanct. I am certainly not against all the good that electronic medical records bring to the party. However, we must first let practitioners do their jobs, not let “data screen medicine” dumb down patient care.

Perhaps provider-run coalitions should dictate standards for ever-improving EHR frameworks and interfaces so their highest-quality, real-time nimble intelligence can be best captured in all patient events. I know at least one nurse practitioner who has a lot to say on that subject.

7 Ways to a Better Work Comp Plan

Although some improvements in workers’ compensation claim results require large investments, resources and complex implementation phases, others require more commitment than dollar investment and are simple in execution yet sublime in positive impact. The seven suggestions that follow are field-tested and proven effective. These seven will not only improve the results of your work comp program but will enhance workers’ respect for their jobs and increase cooperative attitudes. Best of all, these seven can be initiated quickly and with moderate to low effort:

Quick-Tip: Seven Suggestions + Negligible Resources = Zero Excuses

1) Before and after each shift, supervisors can ask if anyone is hurt. This is easy to implement where crews already have before and after meetings. By asking the question, supervisors remind employees that proper work comp reporting is a job requirement. The question also discourages workers who arrive with an existing problem from making it worse on the job or blaming it on the job. This can also reduce late reports. If any injury or illness is identified, then it can be managed immediately.

2) Provide injured employees with a “rights and responsibilities” manual that is branded with the company logo. Many state WC offices provide adequate templates for this purpose. The manual serves as a reminder to employees that the WC process is connected to their employer and their job.

3) Devise a simple monthly WC/safety summary report that goes to executive management. Place a copy on public bulletin boards so staff is aware that executives monitor the related programs. This promotes the seriousness of WC and safety.

4) Work with your third-party administrator (TPA) or insurer to institute a “no fill” list of dangerous narcotic prescriptions that will automatically trigger a refusal and review by appropriate medical resources. Most claim organizations have such lists already. It is a matter of demanding this level of service from your claims or managed care vendor.

5) Require supervisors to make weekly calls to employees out on temporary total disability (TTD) and have weekly chats with employees on modified duty. This would be a simple general talk to ask how they are doing and if they need anything. This is a powerful motivator and reminder of the employee’s value and the fact that a return to their regular job is anticipated. It can also identify problems in the claim that need to be addressed.

6) Write a simple standard “Return to Work (RTW) Expectation” letter that will immediately be given to every claimant’s treating doctor. This will cause doctors to recognize your transitional duty program, understand their expected role and enhance cooperation. The letter will reduce the likelihood of a claimant’s refusal to participate in early RTW and reduce the reliance of doctors on a claimant’s version of RTW opportunities.

7) Make employees aware of WC costs in personal terms. “Dollars” are not as meaningful as referring to units produced or operating time. For example, if employees are aware they work the first 45 minutes of every shift or produce a certain number of pieces per shift, week or month just to cover WC costs they will relate to the problem. Track costs creatively to have impact.

Give these a try. Commit to changing the WC perspective in your organization. My experience says it will pay off.

Promoting Peace of Mind in Work Comp

An employee’s peace of mind is equal in concern with the physical injury when it comes to a worker’s comp claim. An upset employee can lose motivation, incur a bad attitude and rationalize the over-use or abuse of WC benefits. I am adamant that employee satisfaction is as key a factor in WC claim outcomes as it is in overall employee productivity and job performance.

It is not the adjuster’s primary role to manage an employee’s peace of mind at the start of a new report. While we expect good “bedside manner” from an adjuster, she must reserve a defensive position and be a “bad-cop” if necessary. An astute employer sees the opportunity in meeting an employee’s concerns at the time of an injury. It is like adding another critical brick to strengthen the foundation of employee satisfaction.

The immediate task can be simple. A little bit of confident communication goes a long way. Step one is to put yourself in the injured employee’s shoes and imagine being faced with an inability to work. It is not a comfortable feeling.

Quick Tip: Prepare a “Top-10” Information Sheet for Quick Use

Concept: Include a quick-reading “Frequently Asked Questions” checklist as part of an overall information packet for new WC claimants.

Suggested Top 10 and Recommended Answers:

1) Which doctor do I use? – Identify the preferred list, contracted clinic or emergency facility. Explain degrees of employee choice if any does exist in your jurisdiction.

2) What if I can’t do my job? – “If the doctor determines you cannot perform your job, we will try to match you with a temporary alternate assignment. If there is no ability for you to work, your wages will be paid as a WC benefit.”

3) How much will I be paid? – Provide the statutory calculation formula for the comp rate and specify that the employee’s specific rate will be determined by the claims adjuster within 48-72 hours.

4) When do I start getting checks? – Explain the jurisdictional waiting period.

5) How do medical bills get paid? – “All bills will be paid directly to the doctors/providers. You do not pay any bills for accepted and covered treatment.”

6) Do I need an attorney? – “We will help facilitate your benefits. An attorney is not necessary unless you face a disputed issue and want it to be heard by a judge. However, it is your option and right to consult an attorney at any time.”

7) What do I do next? – Explain any other internal steps and forms; explain that an adjuster will make contact and go over additional information. If you have a designated adjuster, provide a name and contact info.

8) What about my health benefits / 401k contributions, etc? – Explain your policies and the jurisdictional requirements that continue benefits during a WC claim

9) Will I lose my job or be fired? – Explain that filing a WC claim is not a basis for termination but also reserve the right for progressive discipline because of safety violations, attendance, job abandonment, fraud and any internal policies that might relate to WC situations.

10) What if I have other questions? – Provide a designated internal WC contact with an open-door policy.

The Best of Claims, the Worst of Claims

It was the best of claims; it was the worst of claims… the age of wisdom, the age of foolishness… belief vs. incredulity… hope vs. despair… etc., etc. The iconic opening paragraph from Charles Dickens’ A Tale of Two Cities makes one realize such conflicts do exist in the same space and time, albeit through different personal perspectives. Such is the reality in workers’ comp claims, where the single biggest factor in outcome is often the claimant’s attitude.

A client claim-audit project offers a jarring comparison between two claim files from different parts of the country. The claims exemplify how little control we actually have over an employee’s attitude in the disability management process, and show how vastly different the human tolls can be.

Both claims were in excess of 10 years old. Both involved exaggerated and evolving symptoms with eventual narcotic prescriptions for “pain management.” At approximately the same time, however, each took a different path.

One claimant found her own reasons and will-power to end the years she spent on prescribed pain-killers. She entered a drug treatment process on her own, eventually stopped her prescriptions and found a full-time job. The other claimant dove deeper into narcotic addiction and exhibited classic drug seeking behavior – such as “losing” his prescriptions and requiring early refills. He tested positive for other illegal drugs once his rightfully suspicious physician initiated a monitoring program.

There was no appreciably different set of claim management tools or tactics used for the claims – the stark difference in outcome came down to the want of the individual… an almost impossible aspect for the day-to-day claim practitioner or human-resources manager to reach or control. And, at the time of my audit, the claims were equally easy to close.

The woman free of prescriptions and carrying a full-time job was simply no longer a claimant. She was probably very happy to have her case closed and the dark chapter of her life over. We decided on an administrative closure of the claim.

On the other hand, the gentleman was barred from his erstwhile treating physician and pain management clinic for abusing meds and refusing a drug treatment program. A host of independent medical opinions indicated the man did not require further meds for the old injury. His everyday behavior was highly unfocused and erratic, apparently causing no attorney to take his WC case. He lived out of a tent in a relative’s backyard.

The man’s claim was also an easy administrative closure because of lack of any foreseeable prosecution. I have to admit his situation nicked at my coat of cynicism, the one layered thick from years in this profession. I hated the plain fact that he was a doomed victim of a WC system enabling his addictive conditions.

To my good readers, I ask: Which closure would you rather preside over?

Quick-Tip: Know When to Hold ‘Em But Don’t Wait to Fold ‘Em

Concept:

When reasonable medical treatment has no impact, quickly consider other options. A claimant with misguided intentions or extraneous problems and no desire to be “cured” might just be his own worst enemy and using the WC claim as a primary enabler.

Suggestions:

– Find appropriate ways to incorporate employee assistance programs (EAPs) or other specialty counseling services to support employees or WC claimants who have debilitating outlooks or possible addiction issues.

– Maintain a “no-fill” position on narcotic prescriptions. This will give you and your defense team at least an opportunity to block dangerous drugs before they are automatically initiated.

– Consider any “chronic pain” diagnosis to indicate maximum medical improvement (MMI). “Chronic” as a term arguably fits MMI. Try to settle the case under that premise. Fight the diagnosis and treatment plan, as a means to pressure settlement. If the plaintiff’s side argues against an MMI determination, then demand a treatment outlook and timeline that results in stopping pain medication.

– For claims with long-term narcotic situations, seek peer reviews to ascertain if the regimes are excessive and if a recommendation for detoxification is appropriate. Specifically set up medical evaluations to confirm addiction and substance abuse tendencies.

– Never presume a claimant with the wrong attitude and bleak outlook will be cured by any type of treatment. Know when you are wasting time and money. You must sense and act on this early. Don’t rely on adjusters to raise questions, as their inclination is to keep treating as long as medical opinion approves. You must take the role of disruptor.

Bottom line” It is distressing that workers’ comp enables addiction. Closing such cases is not always pretty. Learn from the disasters and take more responsibility in the future. Recognize that claimant attitude and outlook are of primary importance, for good or for bad.