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A negative relationship with a supervisor can be detrimental to a workers compensation claim, even before an injury occurs.
A lack of clear communication and misunderstandings about the process can also adversely impact comp claims, especially considering recent regulatory changes that aim to reduce use of pain medications and eliminate unproven medical tests and treatments, and as companies scour for ways to get injured employees back to work more quickly.
Supervisors are on the front lines of effectively managing claims because of their interactions with employees, experts say.
“What happens in the first 30 seconds of the injury has a dramatic effect on what happens in that claim,” said Michael Stack, Kennebunkport, Maine-based principal for Amaxx L.L.C., which provides workers compensation consulting services.
A rough relationship between supervisors and workers even before an injury can lead to a complicated claim, he said.
“It goes into that level of trust,” said Mr. Stack. “If the supervisor responds negatively, that claim can get expensive.”
“If there is a negative work environment and there is no process in place for workers comp, then things go south pretty quickly,” said Aideen Turner, a physical therapist and CEO of Palm Beach Gardens, Florida-based Virtual Physical Therapists P.L.L.C., who has seen workers unmotivated to get better after working for “a bad supervisor.”
“The supervisor often determines whether that employee gets an attorney or not,” she said.
Mellissa Schafer, a Los Angeles-based partner specializing in workers compensation issues for Hinshaw & Culbertson L.L.P., said an employee’s job satisfaction has much to do with a claim’s trajectory.
“When you have an employee who is unhappy and they aren’t getting what they want at work, they don’t want to do a project… that frustration leads to attorneys (in workers comp claims).”
“Start off good and you have good rapport,” she added.
Effective communication on the claims process, applicable regulations and expectations between all parties involved is crucial, experts say.
“The adjuster has to be attentive and explanatory, even if you have a questionable claim,” said Ms. Shafer.
Injured workers face a system unlike that of the past, experts say. Formularies and medical treatment guidelines dictate what medications they can and cannot have, what treatments are medically necessary and what is unproven to facilitate healing.
California, for example, launched its closed drug formulary in January, limiting opioid prescriptions to the first four days of injury. After that, the case heads to utilization review. Workers who have been prescribed opioids are required, by regulation, to reduce dosage, wean or prove medical necessity, according to the formulary.
Eddy Canavan, Orange, California-based vice president of the workers compensation practice and compliance for Sedgwick Claims Management Services Inc., said new regulations can be a starting point for litigation — which might be inevitable, he added.
“My experience is whenever there are changes that impact human beings, there is some litigation that will result from that,” he said. “There could definitely be challenges with the formulary, and applicants’ attorneys will test it.”
But the regulatory changes have been confusing even for employers, experts say.
“I have seen clients say they are having issues with injured workers and they don’t even know what’s going on,” said Jamie Dokovna, West Palm Beach, Florida-based shareholder with Becker & Poliakoff P.A.
Injured workers, grappling with both pain and lost wages, don’t know much about the workers comp process, she added. “This is what creates all the confusion and problems; it makes the employee feel, do I need to get a lawyer because I don’t know what’s going on?”
Claims can also stall unnecessarily because doctors are unfamiliar with the system, said Carin Burford, a Birmingham, Alabama-based shareholder with Ogletree, Deakins, Nash, Smoak & Stewart P.C.
“You get these medical providers that say they can’t respond to (a claims manager inquiring of a worker’s treatment) because of HIPAA and you have to say HIPAA doesn’t apply to workers compensation,” she said, referring to the federal Health Insurance Portability and Accountability Act, which protects patient privacy.
One tactic is for insurers to accept all medical treatments in the first 30 days of a claim, said Mr. Canavan. “Allow a majority of the care in the first 30 days; give the injured worker a better experience for fewer roadblocks later on,” he said, adding that Sedgwick typically — barring state regulations — overrides medical treatment guidelines that call for utilization reviews within that same time frame. For example, if a guideline states a worker with a certain injury does not need a treatment, yet that injured worker wants that treatment, approve it anyway within the first 30 days.
Not delaying services can help the worker overcome initial fears of physical pain, which can prolong a case, said Mariellen Blue, director of case management services with Wayne, Pennsylvania-based Genex Services Inc.
“The fear of pain can impact recovery,” she said. “The greatest opportunity to impact a claim is during that first one to three months.”
Advocacy is a buzz word in the workers compensation sector, but this approach in dealing with injured workers can complicate a claim if communications are misinterpreted.