Maximizing Workers' Compensation Claims Management with a Medical Director

“Call the doctor and let them know if we are going to authorize the surgery,” said a Claims Supervisor to an examiner on the job four-days (who had only one physiology semester in high school).

“I have never made a medical decision in my entire career,” said a WCAB Presiding Judge who had ordered the approval of the fourth back surgery when the consulting physician said the surgery was “inappropriate.”

I have seen many claims professionals, attorneys, and Judges, who are exposed to medical issues daily (incorrectly) assume that they understand medicine. I find it astonishing that non-medical professionals make medical decisions in the Workers’ Compensation claims and medical-legal process. I also find it astonishing that many claims offices and very few defense attorney firms have regular access to a Medical Director. Without proper access to medical professionals in a directed manner, they are unlikely to achieve optimum results for the injured workers and the employers.

I was more than twenty years into the industry before I had daily access to a Medical Director. One day, as I sat in a meeting on a complex treatment process, I heard our Medical Director, Dr. Belsky, give a ten-minute soliloquy on the effectiveness and ethics of facet injections. As he was speaking, he reinforced how important it was for nonmedical professionals such as examiners and attorneys to have regular access to someone who actually knew what they were doing.

The primary result of having a medical director on staff was improved access to quality medical care for our injured workers. The other result was lower total claims costs.

As our Medical Director, Dr. Belsky focused on helping the claims examiners with compensability questions. He also delved into medical treatment issues for our most complex claims (the top 3% of the claims accounted for 60% of the loss dollars) and provided medical expertise to our hearing representatives, who worked to bring the claims to a prompt conclusion.

The workers’ compensation claims process is complex and multifaceted, involving various stages from determining coverage to resolving medical-legal issues. In each phase, the expertise of a Medical Director can significantly enhance outcomes for injured workers and employers alike. The strategic use of a Medical Director in workers’ compensation claims management can optimize outcomes for injured workers and help manage the costs of the claim.

Utilizing a Medical Director is essential for optimizing outcomes for injured employees and employers. By recognizing the value of medical expertise and collaboration in the claims process, organizations can navigate the complexities of workers’ compensation more effectively, ultimately improving the well-being of injured workers and promoting a healthier workforce. It is imperative for organizations to prioritize the integration of Medical Directors into their claims management strategies to ensure the best possible outcomes for all parties involved.

The Role of the Medical Director in Workers’ Compensation Claims Management:

Determining and Assessing Compensability:

• Utilizing their medical expertise, the Medical Director may assess the relationship between the injury or illness and the workplace. By carefully analyzing medical evidence, they facilitate accurate coverage determinations, ensuring that work- related injuries are compensated.
• The Medical Director may analyze medical records and diagnostic tests to help identify pre-existing conditions or other underlying factors that may impact the treatment. This is particularly true for injured workers who are “at risk for delayed recovery.”
• In a legal setting, the Medical Director may provide expert opinions on the causal relationship between the workplace incident and the employee’s injury or illness. Their insights can help the examiner or attorney make appropriate decisions on compensability, ensuring fair and equitable outcomes for all parties involved.
• Reviewing treatment plans proposed by medical providers to ensure alignment with evidence-based practices and promote optimal recovery.
• Monitoring treatment progress and intervening as needed to address any barriers or complications.
• Collaborating with healthcare providers, employers, and insurers to coordinate care and support the employee’s return to work efforts.
• The Medical Director can assist the treating physician work with the employer or the injured worker to overcome problems of kinesiophobia.
• Assessing the employee’s medical condition and functional capacity to determine the appropriate duration of disability.
• Providing guidance on return-to-work options, including modified duties or accommodations, to facilitate a timely and safe transition back to the workplace.
• Collaborating with claims examiners and legal teams to ensure accurate and timely payment of wage replacement benefits.
• Assess the extent of permanent disability and its impact on the employee’s ability to work.
• Providing expert opinions on the employee’s functional limitations and vocational abilities to inform disability ratings and compensation determinations.
• Collaborating with legal teams and vocational experts to ensure fair and equitable resolution of permanent disability claims.
• Reviewing and interpreting complex medical evidence to support legal arguments and defense strategies.
• Providing expert testimony in legal proceedings to clarify medical concepts and refute opposing medical opinions.
• Collaborating with legal teams to develop effective case strategies that leverage medical expertise to achieve favorable outcomes.

Integrating a Medical Director into the claims process to support claims examiners or defense attorneys involves several key steps:

• Establish regular meetings between the claims examiners, the defense attorneys, and the Medical Director to discuss complex cases, medical treatment options, and compensability determinations. These meetings allow claims examiners to present cases and seek guidance from the Medical Director on medical-related issues.
• Implement a process where claims examiners or defense attorneys can submit cases for review and consultation by the Medical Director. This allows the Medical Director to provide expert opinions, review medical records, and offer recommendations on the appropriate course of action.
• Provide ongoing training and education sessions for claims examiners or defense attorneys conducted by the Medical Director. These sessions can cover topics such as medical terminology, injury assessment, treatment options, and understanding medical reports. By enhancing the claims examiners’ medical knowledge, they can make more informed decisions and effectively communicate with medical providers.
• Require claims examiners or defense attorneys to submit proposed treatment plans to the Medical Director for review and approval. The Medical Director can assess the medical necessity of treatments, ensure alignment with evidence-based practices, and recommend alternative options if needed.
• Foster collaboration between claims examiners and the Medical Director in managing complex cases. Encourage open communication, information sharing, and joint decision-making to ensure that medical and legal aspects of the claims are addressed comprehensively.
• Involve the Medical Director in developing policies and procedures related to medical management in the claims process. This ensures the organization’s practices align with best practices, regulatory requirements, and industry standards.
• Conduct regular quality assurance reviews and audits of claim files with input from the medical director. This helps identify areas for improvement, ensures consistency in decision-making, and promotes adherence to medical guidelines and protocols.
• Establish feedback mechanisms for claims examiners or defense firms to provide input and suggestions to the Medical Director regarding process improvements, training needs, and areas of concern. Similarly, provides opportunities for the Medical Director to offer feedback and guidance to claims examiners or defense firms based on their observations and interactions.
• When the claim is settled and closed, have the Medical Director give feedback to the medical-legal doctor on the quality and effectiveness of the medical-legal report.

By implementing these strategies, organizations can effectively integrate a Medical Director into the claims process to support claims examiners and enhance the overall management of workers’ compensation claims.

Integrating a Medical Director into workers’ compensation claims management, or legal offices represents a proactive approach to addressing the complex medical and legal challenges inherent in the process. By leveraging their medical expertise throughout the claims lifecycle, organizations can achieve greater efficiency, cost- effectiveness, and fairness, benefiting all stakeholders.