Concentric Circles of Complexity in Workers’ Compensation Claims

Las Vegas, NV (WorkersCompensation.com) -- The National Workers' Compensation and Disability Conference, held in the Fall of 2023 at Mandalay Bay, Las Vegas, remains a highly attended event for workers' compensation industry professionals. The conference provided unique insights into the workers' compensation process, focusing on the session titled "Follow the Patient Journey: Sidestep Pitfalls Throughout the Life of a Claim."

This panel, featuring Don Adams (President of Effective Health Systems), Erica Fichter (COO of Broadspire), Dr. Gerry Stanley (CMO of Harvard MedTech), and Mike Cirillo (CEO of MyMatrixx), dissected a real-life case - claim number F773491. The subject was claim number F773491, about Lisa Johnson, a 48-year-old office manager at a fictitious Glaskie Manufacturing. Her case, starting with a low back injury on March 5, 2021, and ending in total disability over three years, served as a microcosm of the complexities inherent in the workers' compensation system.

Lisa's journey through the web of workers' compensation revealed significant insights into the interaction between various stakeholders. The panel methodically examined the multi-layered structure of the claims process, with the injured worker at its nucleus. Surrounding this core are concentric circles representing the insured, insurer, claim organization partners and outsourcers, and the medical industry and legislation. Each layer plays a pivotal role, yet the case of Lisa Johnson underscores where these interactions can fall short of their intended purpose.

The detailed review of Lisa's claim uncovered a series of missteps and missed opportunities at multiple points throughout these three years. After the initial treatment plan, a breakdown in the process led to the involvement of an attorney, numerous medical referrals, surgeries, and psychiatric consultations, culminating in long-term disability. This progression prompted the panel to question the efficacy of current practices and advocate for a more integrated, patient-centered approach.

This scenario is not uncommon, as those within the claims management process have seen claims like this occur when a debilitating outcome begins with a back strain. The story told by the panel explained that Lisa woke up on March 22, 2021, had coffee with her husband, and spent time with her daughter and grandchild. She drove to work and called to check in with her mom, like any other day. Three hours later, Lisa pulled a muscle in her back, lifting a box of copier paper from the supply closet, and this injury changed her life forever. Not only did this incident affect Lisa's life, but it also impacted all those around her, creating an undesirable ripple effect for her family, friends, and colleagues.

Lisa's story is not just about the failings of a system; it is a poignant reminder of the human aspect often overshadowed in workers' compensation cases. Lisa is a person. A human being. She is not just an injured worker but a vibrant individual with a rich life outside her workplace. A wife, mother, grandmother, primary caregiver for her mother with dementia, and an active community member, Lisa's life was dramatically altered by her injury and the ensuing complications. What value do we place on the life of an injured human in the workers' compensation system?

The panel emphasized the need to view injured workers like Lisa not just through the lens of their injury but as whole individuals with lives, responsibilities, and roles outside their workplaces. This perspective shift is crucial for a more empathetic, practical worker compensation approach and a dire call for legislation change.

In dissecting the various stages of Lisa's claim, the panel shed light on the critical roles of adjusters, examiners, nurse case managers, and other claims team members. They underscored the importance of each stakeholder in influencing the trajectory of a claim. From initial assessments and treatments to navigating the complexities of legal and insurance requirements, each step plays a vital role in determining the outcome of a claim.

The panel made it evident that the industry needs a paradigm shift. A change that not only addresses the technical aspects of claims management but also embraces a more holistic understanding of the injured worker's life. The panelists argued for a system that balances cost containment and compliance with empathy and thorough care for the individual. The "system" is not limited to claims management, as organizations have a prominent role as employers, and legislation dictates what workers' compensation must provide.

The session concluded with a powerful call to action, echoing the words of John Wooden, "Failure isn't fatal, but failure to change might be." The workers' compensation industry, equipped with knowledge and technology, faces a critical choice: to continue on the well-trodden path or to forge a new one that prioritizes the well-being of its most important stakeholders, the injured workers. The story of Lisa Johnson is a call for change, a reminder that at the heart of every claim is a human being whose life extends far beyond their workplace injury. It is a gentle reminder and a guide toward a more compassionate, efficient, and human-centric approach to workers' compensation, leaving us pondering how to drive impact in 2024.

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