COVID-19. A topic that continues to dominate the worldwide stage as its insidious appendages clench the workers' compensation community. Given the relatively young age of this disease process and the hundreds upon hundreds of articles published, the only completely accurate thing we know is that we do not know everything about this disease. The purpose of this brief paper is to help the workers' compensation professional establish when there can be a realistic expectation of maximum medical improvement. Every jurisdiction has their own definition of maximum medical improvement. Furthermore, as noted in the American Medical Association Guide to the Evaluation of Permanent Impairment, 6th Edition, maximum medical improvement refers to a status "where patients are as good as they are going to be from a medical and surgical treatment available to them." In short, it is not expected further material recovery could arise. Given the relatively young age of this disease process, which was first identified in December 2019 and achieved worldwide pandemic status a few months later, we are continuing to learn additional complications secondary to this medical malady. From a generalized perspective, several conclusions can be drawn even with the understanding that every case is unique. There [...]
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Presumption in workers compensation typically requires that an employer accept full responsibility for certain diagnoses, with presumption laws varying by jurisdiction. And, with the recent pandemic and national healthcare emergency in the United States, presumption in workers compensation can often mean accepting responsibility for the contraction of a highly communicable virus that carries a multitude of implications both for the employee and the employer. In several jurisdictions, the increasing prevalence of COVID-19 has led to modifications of the workers compensation statute to factor in other circumstances that might heighten an employee’s risk of exposure to disease. By this new standard, certain workplace illnesses are presumed to be secondary to occupational issues. For example, some presumption laws assert that certain cancers are a function of occupational exposure regardless of what evidence-based medicine may indicate. With the recent national healthcare emergency in the United States, presumption in workers compensation can often mean accepting responsibility for the contraction of a highly communicable virus that carries a multitude of implications both for the employee and the employer. This broad, vague definition of presumption in workers compensation has made it even more difficult to distinguish between ordinary disease of life and occupational [...]
Earn continuing education credits for free without ever leaving your desk! To help foster the growth and success of our adjusters, C3 is offering complimentary professional development courses for Texas state credit. These courses are fully remote and taught via webinar, so you can brush up on your knowledge of topics such as ethics, impairment ratings and file review all without leaving your desk! Below is a 2021 fall schedule of professional development courses offered by C3 that are available for registration. *Please note: if you are a continued education or HR coordinator who needs additional dates for groups of adjusters between 6-50, please email firstname.lastname@example.org to schedule a webinar for your group. Thursday, August 26th 12PM-1:00PM Pain Concepts for the Comp Adjuster - 1 Credit Hour Since perception and tolerance of pain vary widely from individual to individual, pain is difficult to define and describe. This course will go over the types of pain and how it is defined and considered in workers compensation claims, and why. Register Now Thursday, September 9th 12PM-1:30PM Cost Containment Strategies for Workers Comp Adjusters - 1.5 Credit Hrs A return to basics for adjusters that refreshes what the statute in your [...]
Statistically the most commonly filed workers comp claim, strains and sprains account for nearly half of all reported workplace incidents (according to the BLS). Although these two injuries vary significantly, oftentimes workers are clinically diagnosed with a combination strain/sprain injury, which can cause confusion when it comes to determining appropriate treatment and compensation. To clarify, a sprain is an injury to a specific ligament while a strain is an injury to a muscle. Ligament injuries such as sprains involve a stretching or tearing of the tissue, whereas strains occur in a muscle or tendon and can range from a simple overstretch to a partial or complete muscle/tendon tear. Both sprains and strains are most likely to occur in the manufacturing, moving, transportation, and warehouse industries, however they can happen in virtually any job or industry. Since the treatments, interventions and length of injury for a sprain and strain vary widely, it is imperative that the distinction be made between these two pathologies when accepting a compensable diagnosis for a workers comp claim. Statistically one of the most commonly reported workplace incidents, strains and sprains account for over 30% of all workers comp claims (according to the BLS). Since [...]
Back Injuries What Adjusters Should Know Statistically one of the most common compensable injuries in the workplace, back pain accounts for over 20% of workers compensation claims in the U.S. With half a million employees making back injury claims a year, the cost to employers is continuing to increase significantly. Recent data shows that the cost for an employee back injury can be anywhere from $40,000-$80,000, but the average payout from employers is $24,000. While many of these workplace injuries occur in more physically demanding industries such as construction, there are also a surprising number of back pain claims made by employees that spend the majority of their work day sitting at a desk. This is why it is important for adjusters to understand the various elements of back injuries and how they are treated and compensated in workers compensation claims. Cost containment tools such as Early Compensability Assessments and Diagnostic Re-reads can also offer much-needed clinical insight into these complex claims and help identify key components of a workplace injury to determine what the exact compensable injury is and how it should be treated. Because back injuries can occur in virtually any workplace situation - and [...]
Physician Pre-Authorization One of C³'s most crucial containment tools, our pre-authorization services rely on the expertise of medical specialists to answer specific questions related to utilization of care and claimant treatment plans in workers comp claims. During the pre-authorization process, C³'s board-certified physician reviewers provide medical, evidence-based determinations on medical necessity and assess the appropriateness of the: Proposed treatment Level of care Length of stay Treatment setting C³'s pre-authorization services are quick and efficient, giving adjusters the results they need in less time. And our expert panel of board-certified physicians can provide accurate, thorough reports on a wide array of claims to help adjusters successfully contain costs. The above video features one of C³'s physician panelists Dr. Steven Thornton as he discusses the importance and benefits of utilizing expert pre-authorization services. Call us today at (512) 519-9069 to learn more about C3's superior cost containment services. Learn More
Previously established statutes, rules and provisions regarding workers comp can easily become compromised or manipulated by the nuances of language, making it difficult to reach an objective and accurate resolution. To help clear up some of the problems with interpretation of surrounding workers compensation rules and statutes, a legal concept known as “liberal construction”, coined in 1928, is applied. This concept allows many state statutes, including workers compensation laws, to be construed in a fashion that favors the injured employee. The effect is to give injured employees the benefit of the doubt when dealing with gray areas within state law. The purpose of Worker’s Compensation statutes is to protect and serve injured employees. That said, participating in the workers compensation system requires the injured employee to forgo certain protections. Judicious use of this concept can compensate for this loss- protecting the worker’s interests when adjudicating their claims. A loose (or expansive) interpretation of the statutes is meant to assist the injured worker in any way reasonably possible. In some instances, there may be facts presented as part of the case that the judge can disregard as being tangential or inconsequential. Occasionally this can result in all the facts [...]
When addressing questions related to employer/employee relationships, the first aspect to note is whether the employee in question is a "covered employee" or not. Workers compensation benefits naturally apply to those employees who have established this specific relationship and who fall ill, sick or injured secondary to a workplace hazard or occupational incident. But what about those employers that are not covered by workers compensation? Many states, including Texas, do not require employers to carry workers compensation insurance for their employees. But “going bare” is always at the risk of the employer and leaves them open to litigation and issues of liability. The various protections established in civil court that workers compensation insurance offers do not extend to non-subscriber employers. Therefore, it is the sole responsibility of this uninsured employer to create a work environment that is safe and secure for employees and to establish clear and set expectations with their team. The first step in establishing a positive employer/employee relationship is reassuring employees that the leadership of their company always has their best interests in mind and they will do everything in their power to protect their team from any unforeseen issues. By guarding the interests of [...]
Although each industry comes with its own set of workplace hazards, every employer should put a special emphasis on workplace safety. Though most industries are not necessarily at risk for workplace deaths, a reported total of 5,333 workers died in the US secondary to work related injuries in 2020 – a 2% increase from the previous year. With workplace deaths steadily rising, it’s essential that every employer maintain up-to-date safety protocols and practice diligence in all areas. According to a recent study, the three leading causes of death in the workplace are: Falls from a height Being struck by a moving vehicle Being struck by a falling object While these incidents are not common in most workplaces, there are a few physically demanding industries where adequate safety is crucial to protect a workplace and its employees. Not only can a safer workplace help protect its employees from injuries or illnesses, it can also assist employers to: Reduce costs associated with workers compensation insurance Reduce injury/illness costs Reduce absenteeism and employee turnover These reductions lead to increased productivity, improved product quality and even higher employee morale. And increased morale has a direct effect on the productivity and efficacy [...]
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, [...]