Rising Claim Severity Makes Early Clinical Clarity Essential
Recent studies (WCRI CompScope 2026) have identified rising claim severity combined with the physician panel system setting the narrative as the basis for escalating costs in the workers compensation system. In response, it is clear that claim file handlers of these workers compensation claims needed early, objective, statutorily granted evidence-based medicine supported clinical assessment noting the date of injury, mechanism of injury, objective clinical findings identified in those salient points identified with the medical history so as to establish what actually occurred as a function of the identified event.
Why a Baseline Clinical Assessment Matters
To be clear, this Baseline Clinical Assessment (BCA) is not a substitute for an independent medical examination or assessment of the panel physician. It is simply an opening gambit so that all tools in the claim file handler toolkit are utilized establishing the actual compensable injury sustained, and what the most appropriate treatment might be for that particular pathology. By accomplishing a clear established problem list, treating those identified maladies will limit overall claim costs and can help control claim costs and support more accurate reserving.
What the WCRI CompScope 2026 Data Shows
The WCRI CompScope Benchmarks, 2026 addition establish that total claim costs rose approximately 6% per year between 2022 and 2025. A marked increase from the prior assessment completed before the pandemic. It has also been reported that the average temporary disability duration increased approximately 12%, averaging 13.5 weeks. It was also noted that approximately one in five employees injured or at least 30% more likely to become a high-cost claim. Thus, while overall claim file counts are reported to be decreasing, there are reports that costs per file are increasing. The typical “good news/bad news” type scenario.
As identified in the statute (O.C.G.A. § 34-9-202(a)) the baseline clinical assessment operates on the same underlying principle however, not as a direct exercise of the independent medical examination right.
Why Timing Matters in Georgia Workers’ Compensation
As with everything, timing is the whole game, particularly in Georgia. Noting that the injured individual selects the authorized treating physician from the panel posted by the employer, when the ATP starts writing the clinical narrative, to include the diagnosis and treatment plan, there needs to be independent confirmation of the determinations made and treatments suggested. With respect to causation, the standard that the claim file handlers must deal with, as noted in Georgia SBWC Board Rule 200.1, once the narrative takes hold, cost-containment options narrow, and the expense associated with dealing with those determinations can escalate.
Separating Compensable Injuries From Pre-Existing Conditions
Please remember that as noted in O.C.G.A. § 34-9-1(4) the covered injury must “arise out of and in the course of employment.” A Baseline Clinical Assessment (BCA) reviews the clinical information against that standard, and establishes to an evidence-based medicine standard, in writing, those diagnoses directly related to the mechanism of injury and the objective clinical findings established. The objectification and identification of pre-existing, degenerative, and other unrelated comorbidities is established thereby negating treatment for those unwarranted clinical situations. Given the standard of evidence-based medicine, the medical probability and not simply the mere possibility is established maintaining compliance with Georgia SBWC Board Rule 200.1.
Using Evidence-Based Medicine to Control Claim Costs
Baseline Clinical Assessments can mitigate those comorbidities which can inflate costs, can objectify the appropriate duration of disability, identify nationally published standards in this regard; and is a relatively low cost, rapid screening protocol that can assist adjusters with those files where high-cost claims appear to be on the horizon. This report describes, in plain terms, what actual diagnosis occurred as a result of the reported mechanism of injury, identifies unrelated comorbidities and other pre-existing conditions all to a reasonable medical probability. To be clear, this is not a physical examination and does not substitute for the ATP treatment authority but gives clear direction on how the case should proceed.
A Practical Tool for Better Claim Decisions
The takeaway is that claim severity is trending up nationally and the utilization of these tools enables adjusters an independent read of that clinical information in a clear evidence-based medicine perspective. Try a baseline clinical assessment on one of your files and see how this can help you accomplish your goals. My purpose here is to educate, and by no means provide legal advice. My experience has been the utilization of this tool has been most efficacious.
