The Best of Claims, the Worst of Claims

It was the best of claims; it was the worst of claims… the age of wisdom, the age of foolishness… belief vs. incredulity… hope vs. despair… etc., etc. The iconic opening paragraph from Charles Dickens' A Tale of Two Cities makes one realize such conflicts do exist in the same space and time, albeit through different personal perspectives. Such is the reality in workers’ comp claims, where the single biggest factor in outcome is often the claimant's attitude. A client claim-audit project offers a jarring comparison between two claim files from different parts of the country. The claims exemplify how little control we actually have over an employee’s attitude in the disability management process, and show how vastly different the human tolls can be. Both claims were in excess of 10 years old. Both involved exaggerated and evolving symptoms with eventual narcotic prescriptions for “pain management.” At approximately the same time, however, each took a different path. One claimant found her own reasons and will-power to end the years she spent on prescribed pain-killers. She entered a drug treatment process on her own, eventually stopped her prescriptions and found a full-time job. The other claimant dove deeper into narcotic addiction and exhibited classic drug seeking behavior – such as “losing” his prescriptions and requiring early refills. He tested positive for other illegal drugs once his rightfully suspicious physician initiated a monitoring program. There was no appreciably different set of claim management tools or tactics used for the claims – the stark difference in outcome came down to the want of the individual… an almost impossible aspect for the day-to-day claim practitioner or human-resources manager to reach or control. And, at the time of my audit, the claims were equally easy to close. The woman free of prescriptions and carrying a full-time job was simply no longer a claimant. She was probably very happy to have her case closed and the dark chapter of her life over. We decided on an administrative closure of the claim. On the other hand, the gentleman was barred from his erstwhile treating physician and pain management clinic for abusing meds and refusing a drug treatment program. A host of independent medical opinions indicated the man did not require further meds for the old injury. His everyday behavior was highly unfocused and erratic, apparently causing no attorney to take his WC case. He lived out of a tent in a relative’s backyard. The man’s claim was also an easy administrative closure because of lack of any foreseeable prosecution. I have to admit his situation nicked at my coat of cynicism, the one layered thick from years in this profession. I hated the plain fact that he was a doomed victim of a WC system enabling his addictive conditions. To my good readers, I ask: Which closure would you rather preside over? Quick-Tip: Know When to Hold ‘Em But Don’t Wait to Fold ‘Em Concept: When reasonable medical treatment has no impact, quickly consider other options. A claimant with misguided intentions or extraneous problems and no desire to be “cured” might just be his own worst enemy and using the WC claim as a primary enabler. Suggestions: – Find appropriate ways to incorporate employee assistance programs (EAPs) or other specialty counseling services to support employees or WC claimants who have debilitating outlooks or possible addiction issues. – Maintain a “no-fill” position on narcotic prescriptions. This will give you and your defense team at least an opportunity to block dangerous drugs before they are automatically initiated. – Consider any “chronic pain” diagnosis to indicate maximum medical improvement (MMI). “Chronic” as a term arguably fits MMI. Try to settle the case under that premise. Fight the diagnosis and treatment plan, as a means to pressure settlement. If the plaintiff's side argues against an MMI determination, then demand a treatment outlook and timeline that results in stopping pain medication. – For claims with long-term narcotic situations, seek peer reviews to ascertain if the regimes are excessive and if a recommendation for detoxification is appropriate. Specifically set up medical evaluations to confirm addiction and substance abuse tendencies. – Never presume a claimant with the wrong attitude and bleak outlook will be cured by any type of treatment. Know when you are wasting time and money. You must sense and act on this early. Don’t rely on adjusters to raise questions, as their inclination is to keep treating as long as medical opinion approves. You must take the role of disruptor. Bottom line" It is distressing that workers’ comp enables addiction. Closing such cases is not always pretty. Learn from the disasters and take more responsibility in the future. Recognize that claimant attitude and outlook are of primary importance, for good or for bad.