Medical Considerations For Workers Compensation Claims

Workers compensation insurance is designed to provide treatment to an injured worker to recover from a work related illness or injury.  Workers compensation will partially replace wages lost during recovery and help your employee return to work.

These medical consideration tips will help you evaluate the necessity of some treatments and to verify that your employee’s treatment or care is appropriate.

A Broker at GDI Insurance Agency, Inc. can help you with a complete Workers Compensation program. Contact us at 1-888-991-2929.

Medical Considerations

  • Make sure that your occupational medical practitioner does a thorough and proper examination when an employee first goes to see them; this way, you will not be surprised when the independent medical examiner (IME) tells you that you have a problem claimant. This includes performing Waddell’s tests when there is a lower back injury involved.
  • A diagnosis should be supported by the conditions of the accident. If the two don’t match up, then the diagnosed injury could be a result of something not directly related to work functions. In these situations, be very careful of what you pay for.
  • Don’t pay a bill for a surgery or procedure without reading the operative report. Sometimes it can contain things that had nothing to do with the incident that should not be your financial responsibility.
  • Don’t let diagnostic tests dictate your case management; tests only proves that there is an injury, not whether it happened at your workplace.
  • For a quick and easy way to save money, refer employees to physicians that you trust to provide legitimate findings and diagnoses.
  • Before a surgery takes place, establish whether it was caused by a work-related condition. Doctors may suggest surgery a bit more readily when they know it is a workers’ compensation claim.
  • Make sure that diagnoses are legitimate and universally accepted before you pay a claim. For instance, don’t list “pain” as your work-related diagnosis. Pain is a subjective finding – you cannot qualify it or quantify it.
  • Know the basics about common medical terms that you may encounter. For example, fibromyalgia is not a diagnosis; it is a symptom. The word itself means “pain in the fibrous tissue” (the suffix “algia” always indicates a symptom).
  • Be wary of paying for surgeries or operations caused by arthritis. Arthritis is not caused by trauma and thus cannot result from an on-the-job injury; therefore, in most cases, it should not be considered a workers’ compensation claim. The only exception is arthritis caused by repetitive trauma, found in employees who do a lot of squatting, kneeling or repetitive hand and finger movements.
  • Be wary of other common claims that may be masked as workers’ compensation injuries. For example, in general, trauma does not affect an existing replaced knee, making it rare for necessary loose knee replacement to be work-related.

Legal Considerations

  • Know and understand the interplay between your state workers’ compensation laws, the American with Disabilities Act (ADA), and the Family and Medical Leave Act (FMLA).
  • Keep your legal counsel in the loop on workplace injuries right from the beginning. The first 24 hours after an incident are crucial, and your lawyer needs to be informed about conditions, investigations and any updates.
  • When hiring, provide detailed job descriptions that include an accurate percentage of the amount of work that is physical. This may prevent later legal disputes.
  • Document and file everything throughout the workers’ compensation and return to work process, as it may become relevant information if there is a claim or later dispute.
  • After an incident, review the employee’s personnel file. This will help you understand the employee better, and it may offer clues or tendencies for potential fraud or a vendetta against a co-worker or manager.
  • After an incident, your legal team or representative should do an on-site inspection where the injury occurred. Be sure that they interview others who do a similar job in addition to any witnesses.
  • If there are changes in the diagnosis, the accident needs to be re-evaluated. It may not have happened as reported.
  • Keep an organized case chronology, documenting everything from initial claim to the close of a case. This includes previous history of the employee that may be relevant (past disputes with co-workers, claims history, problems at home, etc).
  • Make sure to provide the IME with everything you have, including your chronology.
  • Before a trial, make sure your witnesses are prepared. Someone from the company should be present at every hearing; it’s important to make sure that everyone is always on the same page.

Learn More About Workers Compensation

Download our “Money Saving Workers Compensation Tips”.  This PDF is full of Workers Compensation strategies that will positively effect your bottom line.

Workers Compensation Savings

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