Subsequent to the recent tragedy in New York City, it is clear that frustrations with the overall insurance process can rise to a level of significant tragedy. It is not lost on those of us in the workers’ compensation ecosystem that similar frustrations are at all to frequent occurrence. Fortunately, to my knowledge, it has not risen to the level of assassination. However, I find it quite astonishing that a number of individuals on social media would endorse this type of action. That is a wholly separate conversation.
I wanted to take this opportunity to outline best practices for those individuals who might find themselves involved in an individual who does not understand the limitations of that workers’ compensation program available to them. We all understand that workers’ compensation is the same except that it is different in every state. Additionally, what was made available for one individual may not be right for his cousin who had a similar injury. It would be incumbent upon you as a worker’s compensation professional to outline the specifics and limitations if any that may contribute to the noted frustration.
When communicating (and abundant and effective communication is the keystone to dealing with denials) you must be clear, direct, and concise. What the injured individual may be hearing from his friend up the street or his cousin or whoever, it may not be consistent with the statutory limitations that are applicable. And while communicating, use plain language that every layman can understand. We all have our jargon, abbreviations, what have you, but this may not be readily clear to that injured individual who needs to understand exactly what is going on.
When denying a claim, or specific intervention, be as specific as possible, site-specific language, rules, statutory limitations, or whatever is pertinent to the decision being made.
One should also show empathy as this clinical situation may be an overwhelming occurrence to this injured individual. All too often we see individuals who believe all of their symptomology and pain is a function of the injury that occurred three weeks ago when it is clear to an evidence-based medicine determination that the noted symptomology relates to changes that are several years old. While showing empathy for the current critical situation this individual is facing, the professional. This professionalism includes a calm, respectful, and courteous demeanor. I know from personal experience this can be a bit of a challenge, but as a Worker’s Compensation professional, it would help your position to keep your composure.
And with any determination, there is always an appeal avenue to be pursued. Outline each of the rights and appeals protocols available to that injured individual. Show them that you have an understanding of their position and that there is no basis for significant frustration when there are other opportunities to pursue.
And lastly, if not most importantly, document thoroughly the conversation, date, time, items discussed, the rationale for the positions taken, and what, if anything, you had offered that individual.
Insurance can be difficult for people to understand and incorporate the limitations of that particular protocol. As we all know, workers’ compensation insurance addresses the sequelae of the compensable lesion alone and does not address unrelated comorbidities. This nuance is all too often lost in those individuals who have other tangential factors compromising their thought processes.