Why the fastest way through a Louisiana Worker’s Compensation file is a clinical read and not a guess.
Workers’ Compensation Claims Are Becoming More Expensive
As noted in the recent WCRI CompScope Benchmarks study, total claim costs have risen approximately 6% per year over the last number of years. It is also noted that the total number of claim files is decreasing. This represents the ultimate “good news/bad news” scenario. The number of files incoming is lessening; however, the severity and treatments are expanding. Another example of this is that average temporary disability duration has risen as well. Another direct driver of increasing indemnity exposure. Additionally, in Louisiana, temporary disability duration is running 9-16 weeks longer than other states in the study.
What Drives High-Cost Claims?
Another statistic identified in this report is that 6% of all claims drive approximately 40% of the total medical payments. This escalation rate is frontloaded, compounding, and claims requiring resource intensive care beyond 12 months are up to 35 times more likely to become a high-cost claimant. Here is the real kicker, concrete risk multipliers include comorbidities found in approximately 1in 5 injured workers, and those injured workers are at least 30% more likely to become a high-cost claim. Another significant risk multiplier is having multiple treating providers addressing the compensable injury.
Claim Creep Starts Without an Objective Clinical Assessment
The takeaway here is that severity isn’t random. It is what happens when a claim file does not receive objective clinical assessment with respect to the mechanism of injury, the diagnosis assigned, and the lack of exclusion of pre-existing conditions. This is the exact scenario where claim creep starts.
How Louisiana Law Supports Early Clinical Review
The statute is clear, La. R.S. 23:1142(B) noting that for nonemergency testing or treatment over $750 requires approval from the adjuster. That determination as noted in the statute is made based on the medical records without an examination. Understanding that a separate section of the statute (La. R.S. 23:1121) allows the employee to select one treating physician for specialty beyond that, employer consent is required. This is an attempt to address the noted “multiple providers early” risk factor mentioned previously.
Having clear objective clinical information as to what actually occurred as a function of the identified event will enable the application of Section La. R.S. 23:1203.1 when addressing if the non-emergency treatment conforms with the OWC Medical Treatment Guidelines. Any disputes must be resolved within a five-business day standard (La. R.S. 23:1203.1(G).
Why a Baseline Clinical Assessment Matters
This is why obtaining a Baseline Clinical Assessment (BCA) enables the claim file handler to have the information necessary to expedite appropriate treatment and fully care for the injured individual relative to the injury sustained. To be clear, this is a record-based review alone, and as noted in R.S. 23:1142(B), no examination is necessary. This provides a rapid set of findings and works towards establishing care required to address the actual sequelae of the compensable event and nothing more.
Early Clinical Insight Leads to Better Claim Decisions
Another benefit of completing the analysis in this fashion is that there is no delayed wait time for an appointment or independent medical examination that may be backed up secondary to scheduling backlog or other parameters. These reports are returned within 3-5 days as opposed to the multiple weeks an IME may require.
A Real-World Example of the Cost of Delay
Consider if you will that establishing the exact pathology enables accurate reserves for the injury sustained. As an example, a construction worker fell, was assigned a diagnosis of a knee contusion, however it was overlooked on history with there was episodes of locking or a lack of extension. This history would indicate a possible bucket handle tear, and if the enhanced imaging studies are not completed for two-to-eight weeks, the reserves could move from $18,000 to more than $200,000. Having an orthopedic surgeon identify the need for MRI early on, enabling surgical intervention to be completed early on, is a huge cost savings tool. This BCA tool is completed within five days, and the objective read provides a number of insights for the injured individual.
Better Information Leads to Better Outcomes
In summary, as reported by WCRI the number of claims is decreasing, however the severity in those claims is increasing. The reasoning for these increasing claims includes multiple providers, on flagged comorbidities, and perhaps a delay in obtaining objectification of the exact diagnosis. The statute (23:1142(B)) allows the claim file handler the authority to obtain a records-based, non-clinical examination assessment of the current clinical state so that the most appropriate treatment can be delivered as expeditiously as possible. The net effect is that fewer files age into that high-cost category, the injured individual obtains appropriate defensible care early on in the process and hopefully reduces the need for litigation.
