There are a variety of issues that come into play in the management of workers’ compensation cases. Health care providers play a key role in these cases when it comes to evaluating the patient/worker, determining whether the worker’s injury or illness is work-related, and facilitating the patient’s return to work.

How often do you find yourself assessing a patient who presents with an injury or illness that may have occurred on the job or while carrying out one of his or her job responsibilities?

In these situations, it is important to have an understanding of workers’ compensation laws and how your assessment of the patient/worker’s injury comes into play.

Workers’ compensation laws were enacted in the early 1900s. The intent behind the laws was to relieve society of the consequences of injury, wage loss and incidental injury expenses that occur on the job. This shifted the burden of this cost to industry. Workers’ compensation statutes subsequently became regulated at the state level.

Most states have regulations that mandate employers to provide certain benefits, including workers’ compensation benefits, to employees. Workers’ compensation statutes vary from state to state. Accordingly, clinicians must be familiar with state laws that may apply to specific situations when they are caring for workers’ compensation injuries and illnesses. In general, as long as an injury or illness arises out of the worker’s employment and occurs during the course and scope of employment, the employer is obligated to cover the employee’s compensation for medical costs and wage loss.

The most important consideration in regard to workers’ compensation cases is to determine if a symptom, illness or injury is due to work.

While the final determination of compensability rests with the company’s benefits administrator or workers’ compensation insurance guarantor, many individuals play a role in making this determination. Granted, healthcare providers provide an accurate medical assessment and treatment of the injury or illness. However, we also assist in gathering and reporting information that is used to make a determination of compensability.

Understanding What Constitutes A “Work-Related” Injury
Within the context of workers’ compensation laws, the injury/illness causation identifies what is at fault, not who is at fault. Primarily, one must determine whether work was the major contributing cause. Issues surrounding causation may affect the worker’s payment for lost time, medical care, rehabilitation and possibly permanent loss of earning capacity.

Despite the fact that states have slightly different legal standards for defining what constitutes a “work-related” injury or illness, the legal distinctions of causality do not alter the medical science involved in establishing an association, or lack thereof, between health and work.

Four Overall Goals To Managing Work-Comp Claims

In order for the incident and resulting claim to be determined as compensable, the injury/illness must meet one or more of the following conditions.

• There must be a causal connection between the injury/illness and employment.
• There must be some risk incidental to or connected with employment.
• The injury/illness must flow from employment as a natural result.
• The injury/illness must occur within a period of employment when the worker is where he or she is to be reasonably expected.
• Work must be the major contributing cause.

In other words, at the time, place and circumstance under which a work-related incident occurs, the worker must be doing what he or she is supposed to be doing at the time and place the worker is supposed to be doing it.

What Goes Into Determining Causation
Determining the causation of an alleged work-related injury/illness is straightforward. However, it does require careful analysis and consideration of all causal or associated factors. The use of medical logic regarding preventative and curative efforts will have financial and legal implications on the case. You must determine if work is the sole cause or if it is one of several causes, any of which could independently instigate the injury/illness.

Sole or direct cause indicates a clear relationship between the injury/illness and the source of the incident. Direct trauma to a body, slips and falls, burns and lacerations most often present as a sole cause.

Alternatively, there may be a combination of factors, some of which are work-related. For example, in cases of hearing loss, repetitive stress and cumulative trauma injuries, one must consider non-work related factors, preexisting conditions and other comorbid conditions when trying to determine causality.

Additionally, the issue of competing causation occurs when either a workplace factor or personal factor could independently be responsible for the adverse health effect. Examples of personal factors include thyroid disease, diabetes and degenerative disease. In these cases, you must consider the extent to which a personal factor contributes to the causality. Accordingly, it is essential to perform a thorough evaluation of the patient and his or her injury/illness when weighing these various factors.

Making the clinical diagnosis in a workers’ compensation case is no different than making the diagnosis in an emergency room, walk-in clinic or in a primary care setting. An ankle sprain is an ankle sprain. The primary difference in managing a workers’ compensation injury/illness is the ability to take workplace factors into consideration.

As healthcare providers, we must clearly assess all mitigating factors to assist the employer or guarantor in determining whether an injury/illness is of a work-related nature. This determination will have an effect on future care, compensability and Occupational Safety and Health Administration (OSHA) records.

With all of these things in mind, providers must clearly communicate the issue of medical certainty to the employer and guarantor. Accordingly, clinicians need to adhere to the following steps.

Clarifying Your Role In Managing Work-Comp Cases
• Conduct a clinical evaluation. Within this evaluation, providers can determine whether the patient has a specific clinical disorder. Once you have determined the diagnosis, evaluate potential causative factors to determine if a specific clinical disorder is present. Did work cause or contribute to the diagnosis? Also assess whether other causative factors are likely. You must clearly define these factors as a part of the clinical evaluation.

• Obtain a thorough patient history. Reviewing a company incident report can give you facts about what may have led to the workplace incident. In addition, obtaining a patient’s written statement of the incident and associated physical complaints is invaluable. Interview the patient to validate and clarify these statements. (See “Key Factors Of The Patient Interview” below.)

• Provide documentation that will aid in the determination of apportionment. Apportionment deals with the distribution of benefits or liability. In the presence of a preexisting condition, a decision will be made in regard to shared or partial liability. Be sure to document information that will assist in making this determination. Accordingly, clinicians should seek answers to the following questions.

Does the patient have a preexisting condition that contributes to his or her current injury/illness?

Do your objective findings represent an exacerbation of a preexisting condition (a temporary flare-up arising from the same etiology)? Alternatively, do the clinical findings represent an aggravation or progression of the preexisting condition or a new event that makes the preexisting condition worse?

Are there other relevant comorbidities that you need to consider in evaluating or managing the care of the patient? Examples include but are not limited to: degenerative disease, obesity, diabetes or other systemic conditions.

Is the injury/illness in question the major contributing cause for the presenting complaint, treatment plan, and functional limitations and restrictions?

• Establish a statement of causation. In this step, clinicians should compare clinical findings to the patient’s medical history and reported events surrounding the incident that allegedly contributed to the injury. Clearly define coexisting complaints, illnesses or injuries. Reviewing whatever personal medical records are available, pre-job placement exams, and/or prior medical surveillance testing may provide valuable information to assist in determining causation.

• Provide a statement of medical certainty. Given the objective findings, one must define the injury, whether there is an occupational cause and any resulting manifestations or disability to a reasonable degree of medical probability. Accordingly, one should consider the biological plausibility. Is there a causal relationship between the alleged incident and the clinical findings? Weigh the case-specific factors. Did the injury/illness happen within the context of the defining factors of the state workers’ compensation statute? Is there associated, specific evidence analogous to the proven causal association?

Most workers’ compensation statutes state that the accidental compensable incident must be the major contributing cause of any resulting injuries. It is our responsibility as healthcare providers to look for objective evidence of impairment and/or loss of function that would support the patient’s symptoms and perceived limitations. One must subsequently report this evidence in a clear, understandable manner to the employer and the workers’ compensation guarantor.

Keys To Coordinating Care And Facilitating The Employee’s Return To Work
Providing effective medical care for the treatment of injuries and illnesses in workers’ compensation cases does not differ from that of any other setting. Medical care should be appropriate for the injury and based on essential consensus data and evidence-based information. There are five key concepts in managing disabilities that provide guidance for making decisions and coordinating care.

Simplicity. Overemphasizing the potential seriousness of a patient’s symptoms can lead to a worker’s overreaction to the injury and have a negative effect on recovery. Institute conservative measures and treat objective medical findings.

Proximity. This involves the need to keep the injured worker emotionally and geographically tied to the workforce. This includes all components that improve the work environment, including physical, mental and social elements. Keeping the employee at work supports a wellness approach to injury management and maintains a productive attitude. Distancing the employee from the workplace supports an illness model and creates a climate in which the employer may lose touch with the employee.

Immediacy. The sense of immediacy reflects the need to deal with work-related injuries in a timely manner. Delays in treatment significantly increase psychosocial issues and promote delayed recovery. Dealing with issues efficiently conveys a positive message that the patient’s well being is of prime importance.

Centrality. All providers involved with the injured worker must share a common goal in facilitating a successful return to work. When medical services are fragmented and divided among different specialists, there is often no one provider who has ultimate responsibility for directing treatment.

Using a primary treating provider approach assigns a specific healthcare provider as a care manager and facilitates a central approach to managing the case. This provider offers a main link into a network of other providers and specialists who are willing to utilize established protocols, provide immediate communication, and establish uniform expectations pertaining to all the injured worker’s needs. Accordingly, the various providers subscribe to a consistent philosophy of care for the injured worker.

Expectancy. The concept of expectancy reflects the idea that the injured worker often fulfills the clinical and labeling expectations placed upon him or her. Often, the healthcare provider or case manager takes on the characteristics displayed by the patient. Providers must maintain an objective view of the case with a vision toward case closure. Establish realistic treatment goals and timelines with all providers and the employer. Encourage self-management responsibility and motivation on the part of the patient.

Determining Whether The Patient Can Return To Work
The ability to maintain the productivity of the worker is essential to effective management of workers’ compensation cases. If possible, one should emphasize work as a part of therapy.

Determine only medically appropriate work restrictions and limitations. Allow the employer representative to assign work within the scope of these restrictions. Companies will provide reasonable accommodations for restricted duty if they support a worker’s return. This maintains the injured worker’s productivity and reduces lost work time.

Key Factors Of The Patient Interview

The ultimate goal in a worker’s compensation case is facilitating maximum medical improvement. This occurs when the medical condition has become stable or requires no further medical treatment. State statutes provide published disability rating guidelines for assigning permanent impairment ratings (PIR) for injuries/illnesses in which one can reasonably anticipate a measurable effect on the patient’s comfort, function or impairment. Each state publishes uniform PIR ratings based on medically scientific findings used by the American Medical Association’s (AMA) Guides to the Evaluation of Permanent Impairment and other well respected disability rating guides.

In Conclusion
The workers’ compensation system offers workers a benefit to cover costs associated with work-related injuries and illnesses. Workers’ compensation laws were enacted to eliminate costly and time consuming lawsuits for workplace injuries by facilitating prompt medical and wage loss benefits in a cost-effective manner for employers.

Today, there continues to be a considerable amount of litigation surrounding workers’ compensation benefits for various reasons. Problems can also arise when employees perceive workers’ compensation benefits as a remedy for social problems because of a lack of personal healthcare benefits or the perception that workers’ compensation provides a better benefit. These issues continue to create challenges for employers and guarantors.

We must keep ourselves familiar with statutory and case law definitions in the state of our practice. Most statutes consider the time, place and circumstance in which a work-related injury occurs.

When handling a workers’ compensation case, clinicians should determine the mechanism of the injury/illness, whether the symptoms fit the injury/illness and whether the physical findings fit with the subjective complaints. Decide apportionment by questioning the patient’s preexisting history and its relation to the presenting injury/illness. Clinicians should then provide or facilitate appropriate medical interventions, and bring the case to a close in a quality, efficient and cost-effective manner.

When handling a workers’ compensation case, clinicians can provide quality medical services, establish positive relationships with employers and address issues of causality when managing the care of injured workers.