Examiners from the Worker’s Perspective

From my perspective, life in the worker’s comp system for my patients has never been more difficult.  The improvement in overall numbers belies the daily struggles of my patients who are admittedly an unusual group.  Many of them have been referred to me after “failed surgery” or have been in chronic pain for many years.  I had one woman who just needed a three level laminectomy and instead underwent an eight-level fusion from T10 to the pelvis.  She became infected and has had 15 operations in 20 months.  Her spine is now fused from C2 to her pelvis and she has significant chronic pain.

I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

  • Respect the injured worker and treat them accordingly.
    • It should be a major part of their orientation and ongoing in-service training.
  • They should not be involved in medical decision making.
    • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
    • This process should be expedited as quickly as possible.
    • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
  • Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
  • They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF