Fraud Vs. a Lesser-Known Risk in Workers’ Compensation
A few weeks ago, I wrote an article on fraud in the Worker’s Compensation system. I emphasized that the actual concept of fraud does not occur as frequently as some individuals might think.
After publishing the article, a long-time friend of mine saw the blog and subsequently gave me a call. We talked about a number of items, however the conversation blended over to the article. He made a point concerning the other end of that spectrum that a dear friend of ours made more than two decades ago. Dr. William Nemeth wrote and frequently spoke about this concept, calling it “Wounded Worker Syndrome.”
What is Wounded Worker Syndrome?
Bill defined this as a wholly preventable condition where injured individual becomes chronically disabled, not because of the severity of the injury, but due to protracted “medicalization,” essentially teaching this individual that they were disabled and could not return to work, and other system incentives reinforcing the notion of disability.
The net result is that the injured individual focused extensively on the pain complaints. While chronic pain is very real, does anyone really have a 9/10 pain every month for 24 months without any specific noted pathology? Or perhaps these individuals lack the functional goals enabling a safe return to work? Dr. Nemeth felt a possible solution to this was early functional restoration. Meaning that after identifying and treating the injury, one should demonstrate/communicate to the injured individual that this is not the end of the road, or the end-all/be-all of their occupational lives.
Understanding the Struggle. Not Fraud, but Dysfunctional Recovery
Understanding that there is a subcategory of injured employees who do not do well, once injured. They are not malingering or otherwise committing a perceived fraud. What is happening is that there is a “struggle” to become more functional, to return to work, and reaching maximum medical improvement. The outcome is that these individuals find themselves utilizing end-stage medications and unfortunately become wards of the Worker’s Compensation system or the state. One of the issues to be addressed under this scenario is to identify the psychosocial comorbidities (biopsychosocial model of pain, fear avoidance, catastrophizing, etc.), and the apparent reinforcement of pain behaviors by clinicians treating this individual.
An oversimplification within the Worker’s Compensation scenario is that most claims follow a predictable path. The injury is noted, clinical evaluation and diagnosis is made, a treatment protocol is started, and the injured individual returns to work. We all know that some claims linger, no improvement is noted, and the costs begin to accumulate. Dr. Nemeth began to discuss this more than two decades ago and it continues to be relevant in today’s system.
I want to emphasize that the individuals who have contracted Wounded Worker Syndrome are not malingering. They are not “faking it.” The feelings they are experiencing, including pain and frustration, are very real. Unfortunately, their outcomes are poor. This current scenario is a combination of medical, psychosocial, and system-driven factors resulting in an overall less than optimal outcome.
Red Flag Claims Handlers Should not Ignore
The question becomes what can you, as the claim file handler do, even if this claim file and the suggested treatment plan do not yet appear to be overly complex. Take note of any red flags, such as ongoing complaints of pain without any specific objective pathology that would be considered causative of the symptom. The medication protocol does not work without a specific explanation, objective findings, or other factors. Treatment interventions show minimal if any functional improvement and there is ongoing reliance on medications. The injured employee continues to seek injection protocols without any significant improvement. As a result of each of these factors, this injured employee begins to identify more with the role of “injured patient” than an individual who sustained a compensable event and should be improving or resolving the situation.
As the individual managing this claim file, thoughtful claimant management protocols really do matter. This does not mean denying care or rushing recovery. However, successful communication with the injured employee is essential, including noting the expectations for any interventions attempted and ensuring that the injured employee understands the basis of evidence-based treatment. Each conversation should include returning to work.
These are several minor steps towards reaching a successful outcome as quickly as possible. This is not about blaming the injured employee. This is about recognizing an unfortunately predictable pattern early and intervening when necessary. Claims that focus on functional improvement, timely (and evidence-based medicine) care, and as early as possible work reintegration all contribute to the successful conclusion of your claim file. When you catch these patterns early and steer toward functional restoration instead of endless medicalization, three things happen: the injured worker regains purpose faster, the claim closes with dignity instead of dependency, and the system actually works the way it was intended.
Final Thought: Use This as a Practical Tool
Please keep the concept of Wounded Worker Syndrome as a practical tool to be employed if any of the red flags noted begin to flap.
