The Role of the Claim File Handler as Gatekeeper
As a claim file handler in the workers’ compensation ecosystem, you and your team are not merely passive administrators of the noted claim. It is my belief you have a fiduciary responsibility to apply every aspect of the statute, working in the interests of both the injured employee and your client the employer. Essentially, you as the claim file handler, are the gatekeeper for medical interventions, financial accuracy, and adherence to every aspect of the applicable statute/rules.
One of the most powerful tools in your armamentarium is the application and utilization of the standards, as noted from an evidence-based medicine perspective. During your review of the medical records, and paying note to the past medical history, there might be little tidbits demonstrating pre-existing pathology. The question becomes, was this pathology, in any way, compromised by the reported mechanism of injury?
Understanding you are not a medical clinician, what you should be obtaining is an independent, objective, comprehensive summary of the medical records presented, designed to establish not only what is a function of the reported mechanism of injury, it is imperative to note what specific findings are not related to the compensable injury.
With modern imaging technology and techniques, degenerative findings can often be distinguished from acute trauma based on morphology, severity, and chronology. With this information you can state with a measure of certainty that some of the clinical findings were, in no way as a function of the identified injury, compromised by the identified event. Using this data, and your understanding of the regulatory frameworks in your specific jurisdiction, this leads to responsible claim file management and a clear direction for the injured individual to take to achieve resolution of the injuries sustained.
What Is an Evidence-Based Medicine Challenge?
Evidence-based medicine integrates the best available clinical research related to the injured employee based on their clinical records. When a specific clinical provider provides a diagnosis, there should be clear objective clinical data correlating the pathology with the reported mechanism of injury. A simple ground-level fall onto the lateral aspect of the right hip did not cause, and clearly did not exacerbate, bone-on-bone arthritis in the contralateral uninvolved left hip.
With this comprehensive clinical evaluation, you are obtaining a thoroughly medically defensible chain of reasoning, establishing the exact diagnosis that resulted from the injury, which would exclude any number of pre-existing and otherwise unrelated comorbidities that may be present. With this medical rationale being objectified, you can contest the extent of injury or otherwise controvert those findings that may lead to extensive interventions, treatments, total joint replacement protocols and in some jurisdictions, exposure for lifetime medical treatment.
Issues such as multiple-level degenerative joint disease do not occur after a single event. Cervical spondylosis or sclerosis, which may need surgical intervention, is clearly not a function of a simple slip and fall. Similarly, a minor knee contusion in an obese 63-year-old individual does not become a “meniscal tear requiring arthroscopy.” Another question that needs to be resolved is if there is a clear clinical correlation between any psychiatric diagnosis, consistent with the parameters noted within the DSM-5, relative to any late onset reported sequelae of the compensable injury should be examined in detail.
A recent cursory search noted that approximately 15% of employed individuals do not have health insurance. This is not to say they do not have clinical issues, only that those noted issues are most probably not a function of or otherwise compromised by the reported mechanism of injury. This is where “injury creep” becomes an issue to be addressed.
As an example, in Texas one simply needs to obtain a detailed review of the clinical records, and with this report, complete a PLN-11 establishing what the accepted compensable injury is noted to be, and what comorbidities are clearly unrelated to the injury sustained.
In Louisiana, the form to be completed is LWC-1002. This form enables individuals to accept the injury and at the same time contest objectified unrelated pathology when there is no specific data indicating any damage or harm occurred for the pre-existing pathology. This would significantly reduce surgery to address the unrelated comorbidity as a function of the compensable event.
In Georgia, the process is a tad more complicated. The key point is that with an objective report noting the sequelae of the identified event, and any other pathology identified, completion of form LW-3 allows for controversion of specific pathology without controverting the entire injury. If necessary, after this form is submitted, appropriate clinical evaluations may be necessary but establishes that certain elements of the pathology are not a function of the identified event.
Strategies for Claim File Handlers
Successfully contesting pathology requires a structured approach:
- Obtain all medical records possible, specifically those recorded in the emergency room, occupational medicine clinic, or the initial clinical evaluation.
- Pay particularly close attention to the reported mechanism of injury, the presenting complaints (specifically the location of the pain), the past medical/surgical history, and the review of systems.
- At approximately 30-45 days from the date of injury, seek a clinical assessment from an objective independent source identifying the actual sequelae of the compensable event as well as notification of all identified pathology that pre-existed the reported injury sustained.
- Pay particular attention to the clinical citations offered supporting the determinations made.
As I have seen on too many occasions, poorly supported diagnoses, or overly vague diagnoses, can easily inflate overall claims cost, duration of disability, unnecessary or excessive surgery, and precipitate uncalled-for litigation. Reliance on the standards of evidence-based medicine restores integrity in the overall claims process, establishes a level of fairness in providing all of the appropriate care of the injured employee, notes compliance with the statutory requirements, and provides that claim file handler with clinical data necessary to communicate to the injured employee and treatment team, which should expedite claim resolution. What all parties see are the objective basis for the determinations made, this should lead to fewer disputes.
