• High caseload – not to be overly simplistic, there are simply a limited number of hours in the workday. Paying attention to an excessive number of cases leads to errors, oversight, and compromising the attention each case deserves. Additionally, studies have demonstrated that high caseloads lead to “burnout” and the sequela is decreased efficiency and utility on the part of that claims file handler. If you find yourself missing deadlines, not effectively communicating, or any other of the noted factors contact your supervisor to see what can be done to resolve this issue.
  • Technology issues – remember the days when there were paper files only? With advances in technology, improved software systems and applications, and the emerging field of Artificial Intelligence (AI), keeping current and up to date with each stakeholder in the process can be a challenge. It is well understood that technology can streamline the entire claims file handling process. However, outdated systems, and inadequate resources for those systems, can contribute to major roadblocks in the claims file handling process. As technological issues can lead to limitations such as inefficiencies, errors, and increased administrative burdens, one must be aware of those limitations and how best to address these issues.
  • Return to work – the literature notes the overwhelming majority of all injured individuals want to return to work. There are those who want to expand the scope and severity of the injury, and this will be addressed below. However, barriers such as employers not wanting to risk additional exposure and thereby not honoring restrictions, providers who place in order didn’t restrictions relative to the actual pathology objectified, and other issues must be resolved. Work with the employer, the provider, utilizing Nurse Case Managers, and getting this individual back to a meaningful and productive occupational scenario will improve outcomes. A number of studies have demonstrated getting an individual back to work often is the best medicine.
  • Fraud – no one likes to speak about this; however, a well-known dark little secret is that there are those individuals who attempt to “get over” or otherwise usurp the workers’ compensation system. These fraudulent claims, or other abuses to the Worker’s Compensation system are issues that must be addressed as soon as they are suspected. Obtaining detailed information regarding the date of injury, mechanism of injury, initial complaints, findings on the initial physical examination, and a notation of the pathology objectified would be crucial to eliminating fraud and abuse. One does understand that such investigations can be resource intensive and consume what little time that claim file handler has to address other files. It is clear that fraudulent claims increase the medical spend, and indemnity outlay, but the return on investment of time is that the integrity of the entire Worker’s Compensation system is maintained. One must be vigilant at each step of the process and if there is the slightest doubt, pursue this vigorously.
  • Delayed reporting – statutorily, there are identified specific parameters with respect to reporting a compensable injury. However, it is particularly difficult to legislatively address medical issues. Repetitive stress injuries are an example. Ignorance of the system is another issue that must be looked at. However, if the claimant reporting is delayed, this is a harbinger of additional issues which can compromise the overall adjudication process.
  • Disputes over compensability – to be clear, workers’ compensation is not health insurance. Workers’ compensation is limited to the sequelae of the compensable injury alone. This is not to say that injured workers do not have significant and often times compromising clinical issues, however, one needs to sort out what occurred as a result of this injury, versus what is a pre-existing, ordinary disease of life clinical situation. All too often we hear injured employee’s essay “I did not have pain before, I have pain now” and all the symptoms are a function of the compensable event. Unfortunately, this is simply not the case. There are tools to be employed to establish what is, and more importantly, what is not a function of the reported mechanism of injury.
  • Coordination of care – speaking as a clinician, I did not take into consideration who was paying for the clinical services to be provided. It was my job to take care of my patient and make sure that all pathology noted was cared for. Unfortunately, the Worker’s Compensation system is not embraced this particular concept, and it becomes confusing and challenging, ensuring that the treatment being provided is addressing the compensable injury alone. If someone has bone-on-bone arthritis, a total knee replacement arthroplasty is indicated. However, making this suggestion in front of the injured employee often leads to them believing the Worker’s Compensation program will be providing this treatment. As such, the claims file handler needs to ensure all parties are instructed as to the limitations of the Worker’s Compensation system, and the proper processes. Coordinating each aspect of care, relative to the appropriate system must be obtained. Additionally hastening certain aspects (such as MRI) should be accomplished as quickly as possible so that the most appropriate clinical treatment plan can be developed. Utilization of Nurse Case Managers is a tool that should be employed to accomplish this aspect of the case.
  • Lack of medical evidence/documentation – unfortunately, there is a diagnosis code for pain. However, pain is not a diagnosis, it is a symptom. The pathology causing the pain is the diagnosis. This contributes to an overall confusion on the part of the injured employee, and frustration when certain aspects of the symptomology’s are not addressed under the Worker’s Compensation system. Therefore, it is exceptionally prudent on the part of the claim file handler to obtain a detailed explanation of all pathology and establish what is, and what is not, a sequela of the reported mechanism of injury. Objectification of the pathology supporting a diagnosis (i.e. sprain) should be obtained as quickly as possible. A painful joint does not equate to a ligamentous injury a.k.a. sprain. This must be clarified as quickly as possible to avoid as much confusion as one can obtain.

Additionally, evaluation and treatment of certain medical diagnoses can become particularly complex, and overlap the identified injury sustained. A macerated meniscus is not an acute pathology and should be excluded. All parties should obtain a detailed clinical discussion in lay terms so that everyone can understand what is going on.

  • Emotional or psychological factors – injured individuals are now experiencing significant emotional and psychological distress. Clearly, any alteration in the occupational endeavors can contribute to additional factors compromising recovery from that injury. These emotional/psychological issues need to be addressed, claim file handlers need to understand that these factors exist and are impairing recovery. Seeking and obtaining additional education relative to these issues would behoove all participants in the workers’ compensation ecosystem.

And the number one item that needs to be addressed is:

  • Lack of Communication – there is no doubt that workers’ compensation can be a particularly complex scenario. The belief system of the injured employee, the intent of the employer, and the nuances of the statutory limitations can confuse the entire situation. In my experience, it would seem that every injured individual has a cousin, neighbor, or someone who is an “expert” in workers’ compensation instructing that individual on how to operate, what to say, and similar issues. It is the responsibility of that case file handler to initiate, continue, and ensure effective communication at every step of the process is completed. Poor communication leads to misunderstandings, delays in care, and aggravating frustrations at all parties. Do the right thing, speak to the injured employee frequently, and make sure that they know what the expectations are, and what can be reasonably expected by the injured employee.