From regular checkups and maintenance to accidents and emergencies, one thing is certain: healthcare is expensive.  And when it comes to workers compensation, the questions of compensability and extent of injury can be much more difficult to answer, leaving adjusters to determine what to do when there is a compensable injury and the injured individual feels that every piece of pathology identified is a function of that injury. In short, how can adjusters identify and treat the components of a workplace injury without inheriting or assuming responsibility for a patient’s pre-existing pathologies?

In medicine there is a saying that “Common things happen commonly and rare things happen rarely.” Given the countless factors and variables involved in workplace injuries including treatment costs, potential fraud and legal precedence, there are several important questions that must be answered before an adjuster can determine compensability. Among these crucial questions are:

  • Was this an acute injury?

  • Is the injury the sole cause for the pathology?

  • Is the noted pathology a function of the work injury or a natural progression of the pre-existing ordinary disease of life?

  • Is this current pathology an aggravation or exacerbation of a pre-existing clinical situation?

Keeping these factors in mind, the designated doctor should ask:

“Was the accident or incident giving rise to the compensable injury a substantial factor in bringing about the additional claimed injuries or conditions, and without it, would the additional injuries or conditions have occurred?”

This should be the standard for both the primary treating physician and any subsequent provider who wishes to extend the original scope of the compensable injury. And any questions related to these additional diagnoses should be clarified by that particular provider. Consequently, all physician responses should be held to an evidence-based medicine standard to ensure that the proposed treatment is accurate and efficacious.

Understanding that numerous symptomologies may be present upon diagnosis, there are certain methods that can be used to establish the exact result of a specific mechanism of injury. The statute indicates that the care rendered must be a sequela of the compensable event. As such, all parties need to establish – to an evidence-based medicine standard – the exact extent of the compensable injury. Obtaining an appropriate and thorough clinical assessment as early as possible when a claim is filed can assist adjusters in understanding what pathology is acute, what is chronic and what pathology actually exists.

It is important to keep in mind that without identifying and establishing the exact result of a workplace injury, related treatment costs can become exorbitant. These tangent pathologies could result in additional treatments, surgeries and other interventions that drive the cost of a worker’s compensation claim. Treating these unrelated comorbidities could likely be far more expensive than treating the compensable injury alone. Therefore, as part of the initial evaluation of the claim, every claim examiner should obtain their own thorough medical history including the exact mechanism of injury (no detail is too small) and all related medical records. By applying these standards of evidence-based medicine, critically evaluating all the relevant information available and obtaining a thorough clinical assessment, claim evaluators can easily establish what the injury sustained is and, more importantly, what is not a function of the identified incident.

A common claim among injured workers is: “I did not have pain before the injury, and I have pain now.” But by carefully reviewing the diagnostic imaging studies (MRI) and noting the STIR sequence or T2 weighted images, evaluators can determine what pathologies (or clinical findings) are acute and what changes noted are chronic, long term, or simply pre-existed the date of injury. The result is an objective, evidence-based medical determination excluding any specific findings that may be the noted pain generators.

Additional issues such as causation, aggravation and exacerbation must also be considered when determining compensation and treatment for an injured individual. For example, did the work injury cause the noted findings or are they simply a progression of pre-existing pathologies secondary to an ordinary disease of life? There are many Appeals Panel decisions (particularly contradictory findings) on this matter, which only serves to muddy the waters further. Fortunately, there are helpful services available to assist individuals in filtering out pre-existing pathologies and focusing on the actual injury sustained. When utilized early on in a claim, services such as peer reviews, early compensability assessments and diagnostic re-reads can help mitigate any inappropriate costs and ensure that injured employees are treated expediently and effectively and can return to work as quickly and safely as possible.