Five Ways Your Medical-Only Work Comp Claims Can Become Costly Indemnity Claims

In the ongoing battle to control your California workers’ compensation insurance costs, the last thing you need is to be making costly mistakes that end up unnecessarily drawing out your work comp claims. But it happens every day, and employers too often find themselves dealing with what they thought was a medical-only claim that has turned into a lost time claim.

How does it happen? Here are five of the most common ways:

1. The medical care misfire. An employee’s family doctor is great for the flu and other ailments, but many family physicians don’t understand the workers’ compensation system or the ramifications of taking the injured employee off work for a few days. We also cannot deny the existence of notorious physicians who are known for their excessive treatment and disability periods.  Various claimants over the years have told their claims adjusters that their physician actually asked, “So how many days off work do you want?” In California, in most cases, the employer has medical control on a workers’ compensation claim through a properly executed Medical Provider Network (MPN). Educate your employees/injured workers of the medical treatment process for industrial injuries and ensure they are routed to an MPN physician. If treating outside the network without authorization, your adjuster should be objecting to the treatment and bringing it back into the network.  Finally, if you notice a trend with a particular physician that brings up a red flag, advise your TPA of the issue and have them reevaluate the physician’s status with the MPN.

2. The “no big deal” claim. Some employees, worried about what their coworkers will think or what their employer will do, won’t report an injury or will state that the injury is “no big deal” and keep working. Before they know it, a strained muscle that’s already weakened from the initial injury has been damaged further – and before you know it, two weeks of light duty has turned into two months of temporary total disability. Foster a culture of trust in your company, make it clear that every injury needs to be reported, and assure your employees there won’t be negative consequences for filing a claim.

3. The brush-off. One of the biggest mistakes you can make is to ignore medical-only claims, thinking they’re insignificant. If you don’t nail down the precise nature and extent of the injury early on in the game, you could be asking for trouble. An employee who strains his back and is simply sent to the doctor with no follow-up might take advantage of the situation. Let’s say he’s had a neck problem for many years and he decides to inform the doctor that the neck was also injured in the work incident. Now there are multiple body parts involved, greatly increasing the chance the physician will take the employee off work, with the workers’ comp insurer now covering the medical care and lost time for that preexisting neck injury.

4. The questionable claim. When an accident happens with no witnesses and the employee has subjective complaints of pain and strain, be alert. It’s up to you and the adjuster to derail fraudulent claims before they become lost time claims. If you suspect a fraudulent claim, conduct an in-depth investigation, and contact the doctor’s office immediately – even before the employee shows up for the initial visit – to advise the physician of your modified duty program. It also helps if employees know that workers’ compensation fraud will be prosecuted, so be sure to post anti-fraud posters around the workplace.

5. The incredible expanding claim. Occasionally a dishonest employee with a valid but minor injury (such as bruises from a trip and fall) will exaggerate or falsify symptoms in an attempt to get more time off or more money out of the claim. It’s vital that you control the medical aspect of the claim and offer light duty work. Make sure your employees understand their obligations when an injury occurs, and that transitional duty is available and expected of all injured workers.

Every claim matters
Take a proactive interest in every one of your workers’ compensation claims, not just the most severe ones. By staying engaged, you can prevent many of your medical only claims from transitioning into costly lost time claims.

For more ways to control your worker’s compensation costs, contact the California workers’ compensation professionals at Republic Capital. We can help you change your company’s perspective on medical only files, connect you with an MPN vetted for quality physicians and provide proactive claims handling. Refer to our website for more information.