I am not sure why this popped into my head, but I was thinking about a song from the mid-80s from Dire Straits, the song “Money For Nothing” in the first line (and I will take the creative license with the lyric) “Money for nothing and your ‘checks’ (my bad) for free.” It seems a frequent consideration that a percentage of work comp claims are perceived as being embellished, fraudulent, or otherwise considered as a winning scratch off ticket. We know this is not the case, however, it must remain a possible consideration.
When a Workers’ Compensation Claim Begins to Change
Over my years as a cost-containment professional, I cannot tell you how many times we have seen this scenario. The claim starts relatively straightforward, and with time and multiple additional conversations, the claim becomes something completely different. Additional body parts are reported to be part of the injury, ongoing symptomology that does not coincide with the objective clinical data provided, and the overall situation worsens as opposed to improve given the treatment rendered. At times, the treatment escalates without any specific objective clinical rationale to support this increase in complaints.
The Importance of Objective Clinical Evidence
One of the advantages you, as an experienced claim file handler, have is your experience. You can see what the original complaints were, noting the original mechanism of injury, yet the overall symptomology increases. What will help you most dramatically is having that objective clinical assessment ascertaining what actually occurred because of the identified event.
As I think about this, it became abundantly clear that you as a Worker’s Compensation professional must protect the claim integrity from day one. There are any number of tools available, however the one most beneficial and cost-efficient is our Baseline Clinical Assessment (BCA). A Baseline Clinical Assessment lets you know what pathology yours is, and more importantly, what noted symptomology or other pathology is not a function of the identified event. Having that medical assessment in your back pocket enables you to spot those red flags.
At times, I call this a Claim Drift Phenomenon. One would strongly suggest that every claim file professional watches for these “drift” indicators:
- changes that do not match the medical evidence
- there is frequent or high-cost treatment utilization
- there are noted behaviors and reporting inconsistencies such as missed appointments
- shifting symptoms or escalation in the reported mechanism of injury (e.g., a 20-pound box becomes an 800-pound log with one other individual)
- the continued use of opioids without noted improvement in the overall clinical situation or pain score.
Any of these should be the initiation of a comprehensive assessment relative to the current state of the claim file.
What should you do? The answer is easy, obtain competent, objective, and independently confirmable medical evidence to support the clinical situation. If none is available, take every available step to objectively define and document the exact extent of the compensable injury as it actually occurred. Let the BCA be your clinical foundation for doing just this.
Understanding the Difference Between Claim Drift and Fraud
The bottom line is that not all deviations from the normal constitute fraud. Unfortunately, this does occur, however, before you pull the trigger ensure that the clinical facts support your determination. Narratives change. Appropriate treatment can escalate depending on additional clinical facts. Communication between the treating provider and you may not be optimal.
However, when you have a comprehensive objective clinical assessment noting the exact sequelae of the identified mechanism of injury, (at the time of the initial injury) when the overall claimant drifts away, there needs to be specific objective data to support this drift. An earthquake in the middle of the Pacific Ocean can cause a tsunami in Japan. However, one is able to objectify that earthquake, and without such data that tsunami does not appear to be a function of the noted event. Preparation before the tsunami hits in the form of a Baseline Clinical Assessment may be your best insurance against those damages.
