Five Best Practices to Ensure the Injured Worker Comes First

An advocacy-based claims model can improve claim outcomes, lower costs and improve workplace productivity

By Dr. Laura B. Gardner, Vice President, Products, CLARA analytics

Putting the injured worker first is key to the “advocacy-based claims model,” which puts the worker at the center of all activity. “It focuses on improving the injured worker’s experience. Until now, most employers have focused on corporate outcomes. Goals such as cutting costs and reducing days lost. But experts now say focusing on the worker can improve all outcomes.”

The stories of three injured workers provide an opportunity to see the importance of focusing on the injured worker.

Take Melanie. Melanie was working as a lifeguard for the summer at a recreational center. She slipped on some wet pavement that had been targeted for cleanup but not yet addressed. She fell on one knee, sustaining a shattered patella and a deep laceration.

Melanie needed immediate surgery for the laceration. She initially was put into a brace to stabilize her patella but was told by a different provider that she didn’t need the brace. She recalls feeling like there was a lot of uncertainty around how to treat her shattered patella. One provider told her he could wire it together with surgery; another said surgery would be a mistake. Ultimately, after a delay of almost a year, during which she was unable to work, she was referred to physical therapy.

Melanie found the physical therapy helpful in enabling her finally to go back to work. However, she was left with a great deal of concern about the future of her knee and the possibility of late-onset complications. She was also upset about the long delay before she could start physical therapy. Because of this uncertainty, and in order to ensure that her knee would be taken care of regardless of what happened to it in the future, Melanie retained an attorney to help her obtain lifetime medical benefits for her knee. Her claim is still open.

Amy’s story has a bit of a different take. Amy was working as an administrative assistant for an apartment complex. A large number of boxes were delivered to the office and were stacked up against her desk such that she couldn’t leave her desk area without climbing over the boxes. She asked her manager to move the boxes several times, but they were not moved. At one point, while climbing over the boxes, she fell and injured one knee.

Amy reported the injury to her supervisor who wanted her to go immediately to a hospital emergency room. Amy did not want to wait in an emergency room and successfully argued in favor of seeing an orthopedist the next day. The orthopedist obtained an MRI of her knee that showed both old, long-standing damage and newer areas of injury consistent with the fall Amy had just sustained. However, the day after her injury, Amy’s employer fired her.

The payer in Amy’s case tried to deny the claim based on the older damage in Amy’s knee. Amy did not deny that she had damage from years of being a dancer, but she felt it was the newer damage that was limiting her mobility as she had previously been able to exercise and now had too much pain in the damaged knee to work out. She simply wanted the payer to pay for a few sessions of physical therapy, but the claim denial coupled with being fired left her with no resources to pay for physical therapy.

Amy found the claims adjuster hostile and inflexible. She felt betrayed by both her former employer and the payer for her claim. She retained an attorney to fight the claim denial. Eventually, the claim was accepted, and Amy was given several sessions of physical therapy. By the time this came to pass, Amy was suffering pain in the other knee secondary to having to favor the injured knee. What could have been resolved within a limited time had morphed into a time-lost claim with the need for extended physical therapy.

Last, there is Arthur. Arthur was employed as a consultant for a nationally known consulting firm. One day, he was carrying some boxes filled with reports when he dropped a pen and tried to pick it up without dropping the boxes. As he twisted his body to try to pick up the pen, he felt a “pop” in his back and fell to the floor in pain. After a minute or two, he was able to get up without assistance, but the pain in his back remained.

Arthur was knowledgeable about the workers’ comp system and decided to file a claim. His pain was persistent and intrusive, but Arthur was still able to work, so his was a “medical-only” claim. Arthur told the claims adjuster that he wanted to see his own physician with whom he already had a relationship. He alluded to wanting “to avoid retaining an attorney if at all possible.”

After obtaining an MRI, Arthur’s physician told him that he now had a protruding disk that he was going to have to deal with for the rest of his life. Arthur’s physician gave him the evidence-based statistics about the success rate of surgery for a protruding disk, which were not good, and recommended that he avoid surgery and deal with his problem with stretching and physical therapy.

Arthur told the claims adjuster that he preferred to have physical therapy over surgery. The claims adjuster not only approved the physical therapy but also, unsolicited, ordered a special desk chair for Arthur to use in his home office. Arthur felt well taken care of, and after six months of following the regimen his physical therapist had designed, Arthur’s back pain resolved, and his claim was closed. He had not needed an attorney and was extremely satisfied with how his claim had been handled.

What can these three journeys tell us about how to put the injured worker first? Here are five best practices:

  1. Ensure the injured worker is educated about the claims process and what to expect. One of the most common reasons injured workers retain an attorney is because they are worried about whether their claim will be accepted and their bills paid. Reducing uncertainty and fear on the part of the injured worker improves his or her engagement in the treatment process and reduces the attorney involvement rate, which improves quality of care and reduces cost.
  1. Use technology to facilitate the injured worker’s interactions with other stakeholders, from the initial reporting of the injury (think mobile app, direct self-reporting of injuries) to selection of the right physician and finally to the collection of feedback from the injured worker on their treatment. Technology is a powerful tool to provide high-quality, personalized yet cost-effective service. However, it needs to be backed up by strong operational processes.
  1. Encourage injured workers to plan on returning to work right from the beginning. This means helping them select the right physicians proven to have good outcomes and encouraging them to be partners with their treating physicians in choosing wisely among treatment options. For example, there are several physicians who are waging an admirable fight against the opioid epidemic and pushing for more holistic pain-management techniques. We need to send more injured workers to them instead of physicians who have been proven to encourage opioid use.
  1. Trust the injured worker to want to return to work as soon as possible. Most injured workers honestly want to recover, not to game the system. We need to go with that assumption upfront. A good marriage of Math+Trust can help reduce attorney involvement in claims from 13 percent to 4 percent.
  1. Stay in close contact with the injured worker; keep the lines of communication open. Use this opportunity to determine if there are any treatment delays that can be mitigated or any questionable treatments that are being recommended. Expectations on communication speed have increased in this constantly connected world. We need to be as close to them as possible throughout their journey to recovery.

Gently guiding the injured worker to the best possible course of treatment will optimize outcomes, improve injured worker satisfaction and minimize costs.

The primary purpose of the workers’ compensation system is to get injured workers back on track rapidly. As an industry, it’s time we realigned ourselves toward that goal. Using the “injured worker comes first” principle as a true north improves claim outcomes, lowers costs and improves workplace productivity. No longer do you need to make false trade-offs between cost and quality, cost and speed, etc. Just focus on getting the worker back on their feet fast. All operational metrics will follow.

As first published in Claims Journal.



Laura B. Gardner, M.D., M.P.H., Ph.D., is Vice President, Products, CLARA analytics. She is an expert in analyzing U.S. health and workers’ compensation data with a focus on predictive modeling, outcomes assessment, design of triage and provider evaluation software applications, program evaluation and health policy research. She is a successful entrepreneur with more than 20 years of experience in starting and building Axiomedics Research, Inc.


More Stories By CLARA Analytics

Laura B. Gardner, M.D., M.P.H., Ph.D., is an expert in analyzing U.S. health and workers' compensation data with a focus on predictive modeling, outcomes assessment, design of triage and provider evaluation software applications, program evaluation and health policy research. She is a successful entrepreneur with more than 20 years of experience in starting and building Axiomedics Research, Inc.

Dr. Gardner earned her bachelor's degree in biology (magna cum laude) from Brandeis University, her M.D. from Albert Einstein College of Medicine and both an M.P.H. in health policy and a Ph.D. in health economics from the University of California at Berkeley. As a physician, she is board certified in General Preventive Medicine and Public Health and is a fellow of the American College of Preventive Medicine.

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