medical mismanagement claims

What Are They Doing to Me?: Injured Workers, Employers, Insurance Companies & Workers’ Compensation: What You Need To Know

Many times, Injured Workers wonder why certain things are happening on their claim.

Common questions are:

• “Why is my Employer treating me differently now that I am injured?”

• “Why is the Insurance Company not trying to help me?”

• Why is my Employer or Carrier acting this Way?

There are reasons that can explain your Employer’s and Insurance Company’s behavior.

A good way to understand their behavior is to examine the Workers’ Compensation Industry.

The Workers’ Compensation Industry includes Employer Organizations, Carrier Organizations, Medical Provider Organizations, and Non-Medical Provider Organizations such as Private Investigators and Providers of medical equipment and supplies. These groups frequently meet to discuss issues with respect to the handling of claims and other workers’ compensation-related issues. Studying their interests, concerns and motivations allow us to better understand their actions.

In a recent brochure for an upcoming Workers’ Compensation Industry Seminar, there were a variety of topics that the seminar was to cover. These seminar topics ranged from Currently Trending Issues in workers’ compensation to the basics of Claims Management. The seminar topics are enlightening to Injured Workers who wonder what is going on with their claims.

Some of the topics were as follows:

• “The Pitfalls and Challenges in Treating the Addicted Patient;”

• “Disability Prevention: What’s Needed to Keep Routine Claims from Deteriorating;”

• “60 tips in 60 minutes-Avoiding Medical Mismanagement Claims Fallout;”

• “A Futuristic Look at Disability and Absence Management;”

• “Tips for Pushing Past Claims Roadblocks;”

• “Innovation, Forward-Thinking for Managing the Unmanageable;”

• “Cross-Jurisdiction Workers’ Compensation Issues;”

• “Managing Amputation Cases for Optimal Outcomes;” and

• “Mergers & Acquisitions: Proceed with Caution or Advance with Agility”

What Do These Topics mean to Me, The Injured Worker?

The topics give us insight as to what the Employers and Insurance Companies believe is important for them to handle their job of managing the risks and costs of workers’ compensation claims. Minimizing the costs to deliver workers’ compensation benefits is the ultimate goal fo most insurance companies.

In the next part of this article, I will go through each and every topic and discuss how it impacts Injured Workers. In this exercise, I am not going to address these actual seminars and what was discussed. Rather; I am taking my experiences as a lawyer in the field and my attendance at a variety of different seminars to provide you my thoughts.

What Does the Topic “The Pitfalls and Challenges in Treating the Addicted Patient;” mean to Injured Workers?

This topic shows the concern of the industry with respect to “addicted patients.” This topic can be viewed as two-fold for Injured Workers. The first notion coming from this topic would be the sense that one solution to the problem of “addicted patients” is to prevent them from happening. A simple notion to this would be to stop providing or authorizing addictive medication as part of treatment. “Treatment Denial” may be one element that may be raised as a solution. Further, they recognize the fact that “addicted patients” can be problematic can lead to a claim developing red flags will trigger issues which the insurance company will explore.  These issues include of medical mismanagement claims, detoxification, and patients who become dysfunction, as a result of these medications.

Meaning to Injured Worker: If you are an Injured Worker who has been prescribed opioids or other addictive medications, the spotlight may be one you. There will be attempts to deny treatment and wean you off of your medications. Also, there may be medical management intervention to try to address addiction issues. This intervention can include nurse case managers and the employment of a detox program.

What does the topic “Disability Prevention: What’s Needed to Keep Routine Claims from Deteriorating” mean to Injured Workers?

A Disability can mean when an Injured Worker goes off of work. This seminar topic may involve issues such as providing prompt medical assistance, providing an aggressive return to work program, and the assignment of nurse case managers onto claims to minimize the disability. It may also involve issues such as early settlement, early medical evaluations and prompt resolution of claims.

Meaning to injured Worker: The Carrier will try to control case from the very onset. The Carrier will try to limit medical care and the payment of your benefits. They may simply deny the claim. The Carrier and your Employer may try to get you back to work as soon as possible. This can be modified, alternative, or regular duty.

What does the topic “60 tips in 60 minutes-Avoiding Medical Mismanagement Claims Fallout” Mean to Injured Workers? 

This topic implies that there is Medical Mismanagement Claims Handling. Medical mismanaged claims in workers’ compensation can occur in many ways. First, Employers can delay in sending workers for prompt medical attention causing the medical problems to get worse. They can send them to the wrong doctor to provide care. This can delay proper care and recovery. Second, Insurance Companies can refer Injured Workers to the wrong providers who fail to provide adequate treatment. This can include improper treatment or returning workers back to the job too early. An improper Return to Work can end up with the Injured Worker reinjuring themselves. Third, there can be Injured Workers who choose their own doctor who does not provide proper care.

Solutions to these problems can include Nurse Case Manager involvement. It can intervention of the parties to discuss getting proper treatment for the worker involved. Settlement of the case may be something to discuss as well. Medical Malpractice issues may be discussed when there is medical mismanagement claims.

Meaning to Injured Worker: You could have medical mismanaged claim. Do not assume that the Insurance Company is doing the right thing. If you are not getting proper medical care, you need to make it known to all parties so that it can be addressed. It may include obtaining new providers, second opinions, or the use of a medical evaluator.

“A Futuristic Look at Disability and Absence Management”

The futuristic look at disability and absence management can apply to the use of software programs which can monitor an individual’s absenteeism. One of the common issues which Employers frequently look at is missed time from work. This can include workers missing days before or after scheduled days off, ie. Fridays and Mondays. Also, there are issues of absenteeism that occur before or after holidays.

Disability and Absence Management may include Social Media. Strategies to address this concern may be the employment of accessing the Injured Worker’s Social Media Accounts to find out their activities on their days off. For example, is the disabled Injured Worker partying it up in Las Vegas when they should be recovering from their injury? The pictures posted online that are time dated would certainly be of interest to both Employers or Carriers.

Also, with the advent of video cameras at work, your activities can easily be monitored. They can observe you walking, lifting and performing a variety of activities. This video can be shown to medical providers to assess your condition. This can also apply to the causation of injury. The tape can be pulled for the date of the injury to see what exactly occurred.

Also, Disability Management may include Return-to-Work issues and how they can be addressed. Perhaps, workers can be provided with work that they can do online while they are home recovering.

Meaning to Injured Worker: Watch out! Big Brother may be watching you. You should be careful when you take time off of work. You should be careful with posting information on social media. You should be mindful that you are being observed at all times in the workplace.

“Tips for Pushing Past Claims Roadblocks”

This topic implies that Claims creates new roadblocks. Tactics and Techniques of Insurance Companies are needed when they mess up claims and create problems that prevent them from proper claims’ handling. This can include delays in setting up claims, delays in disability payments, delays in providing medical care, and delays in resolution of the claim. Some of the tips I would believe they would recommend is getting more money to resolve the claim, getting rid of the adjuster on the file, getting rid of the attorney on the file and, getting rid of the Claims Manager. Also, staffing files with the adjusters and round tabling the claim with additional claims people to come up with different strategies would be recommended.  Also, setting up meetings with the Employee or their representative may also be effective to bring claims closer towards resolution.

Note to Injured Worker: Insurance Companies may have issues that make them become dysfunctional. You may be dealing with a dysfunctional adjuster or carrier. You may have to get someone on your side to push through the roadblock. It may be your Employer or an Attorney.

What does the topic “Innovation, Forward-Thinking for Managing the Unmanageable” mean to Injured Workers?

This topic admits that claims can get out of control. There can be chaos in the handling of claims. This topic will most likely include different ways to handle claims. Innovation and Forward Thinking may include taking on a grand plan to try to resolve matters when there is a dumpster fire occurring in their offices. In all businesses, there are times in which there is a need for organizational change to improve the culture and productivity.

Note to Injured Worker: In the event, you are dealing with a dysfunctional carrier, your claim may become an experiment. They may be trying a new approach to try to get better results. There may be a re-set button pushed in the Claims Offices on your file. Some of these approaches may be good. Some may be bad. Certainly, changes may lead to a mixed bag of results.

What does the topic “Cross-Jurisdiction Workers’ Compensation Issues” mean to Injured Workers? 

Cross-Jurisdiction workers’ compensation issues can relate to workers who have jobs that place them in multiple states with respect to either the employee’s residence or location of work. Each state has its own workers’ compensation system. Employees legally may have options to file their cases in different states. Each state system may have different benefits. Some state workers’ compensation systems may have better benefits or better access to medical care than others.

Note to Injured Worker: Employers and Carriers may strategically try to get you to file your claim in the state most advantageous to them. Also, they may attempt to move your claim from one state system to another for the purposes of reducing claims’ costs.

What does the topic “Managing Amputation Cases for Optimal Outcomes” mean to Injured Workers? 

Amputations cases can be complicated. In California, total temporary disability benefits are extended out to 5 years for amputation cases. They can involve issues of multiple surgeries, psychological concerns, employment accommodation concerns, prosthetics issues, permanent disability concerns and life-care plans. These can be expensive cases and attempts for cost reduction will most likely be discussed.

Note to Injured Workers: If you have an amputation case, you may be getting special attention from the Claims Administrator. Nurse Case Managers may be involved from the very beginning. Also, the Employer and Carrier may want to push to you re-enter the labor market. Also, the Claims Administrator may be fully versed as to the problems that amputees face. In sum, taking care of your claim properly can save Insurance Company money.

Also, off the topic, your Employer may be concerned about the events of the accident as to the fact that outside agencies such as OSHA may want to investigate and level fines.

What does the topic “Mergers & Acquisitions: Proceed with Caution or Advance with Agility” mean to Injured Workers? 

This topic may discuss issues when Insurance Companies merge or acquire pre-existing claims from another company. It notes that there will be problems with the handling of the claims. Also, it appears to include the concept of being able to make quick moves and being able to adjust to the handing of existing files. Within that, it would appear quick and accurate assessments should be made, action plans are made, and perhaps attempts to do mass settlements may be included. There may be continuity issues which would be recommendations to retain staff from prior claims’ organization if possible.

Note to Injured Workers: When your Claims Administrator changes, Insurance Companies know that there will be problems. There will be possible delays in medical care, benefits, and settlement of the case. Also, there may be new and different procedures in place. You may also get a new adjuster on your file. Expect some bump in the road with respect to the handling of your claim.

What If I Need Advice?medical mismanagement claims


If you would like a free consultation regarding your workers’ compensation claim, or if you feel you have medical mismanagement claims, please contact the Law Offices of Edward J. Singer, A Professional Law Corporation. They have been helping people in Central and Southern California deal with their workers’ compensation cases for 26 years. Contact us today for more information.

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