Conference Recap
Workers’ compensation can seem complicated because it sits at the intersection of law, medicine, and claims administration. During a WCI session designed for professionals both new and experienced, a judge, physician, and claims executive broke down the fundamentals and shared lessons from their respective disciplines.
At WCI, Presiding Judge Robert Rassp of California’s Division of Workers’ Compensation, incoming Concentra Chief Medical Officer Dr. Jill Rosenthal, and Sedgwick Vice President of Workers’ Compensation Practice Scotty Benton explored foundational workers’ compensation concepts for both beginning and seasoned professionals.
Was it an Injury? Was it the Job?
For starters, Rassp explained that before workers’ compensation is a consideration, the injury must meet the “AOE/COE” requirements, meaning that it must arise out of employment and occur in the course of employment.
“AOE is a medical issue,” Rassp explained. “COE is a legal issue, essentially referring to the time, place, and manner of injury.”
But what if an injury doesn’t happen at once but occurs because of years on the job?
“That’s a cumulative injury,” Rassp said. “Which is just to say that it occurred due to repetitive exposure over time.”
Rassp also highlighted Golden State specifics. For example, whereas much of the country refers to workers’ compensation “claimants,” California uses the term “applicants.” In terms of the court system, workers’ compensation claims first go to judges, then an appeals board, then the state’s District Court of Appeal, and finally to the California Supreme Court.
State variations are part of what makes workers’ compensation seem complicated, Rassp pointed out.
“The average length of time to resolve a claim in California is seven years,” Rassp said. “In Florida, it’s 250 days.”
What about attorney involvement?
According to Rassp, attorneys and insurers who want to avoid litigation must think about how they handle denials.
“The number one reason why an injured worker goes to an attorney is because someone said no,” he said. “Either the employer or adjuster told them no.”
Additionally, Rassp advised keeping the focus on the person behind the claim and approaching that person with empathy.
“For most injured workers, this is the first time they have been involved in the legal system,” Rassp said. “It’s something they’re not prepared for.”
Medical Considerations
Rosenthal echoed the need to keep comp human.
“It’s way bigger than what we sometimes think from just looking at the file,” Rosenthal said. “And we’re talking about getting workers better faster in a way that is sustained for their recovery and return to work.”
Addressing the issue of multi-jurisdictional challenges, Rosenthal recommended visual aids.
“If you have multiple states, make a grid,” she said. “Include on it what your states say about who controls where an injured worker gets their care and what does it look like?”
That means identifying common workers’ compensation terms and documenting how those terms are defined from state to state.
“For example, a ‘network’ in Florida might be a discount, while in Illinois an employee gets to pick their provider,” Rosenthal said. “So, you want to know who’s picking — is it the employer, the employee, the attorney — and how will it impact care?”
And speaking of care, Rosenthal’s medical background means that she is especially concerned about the treatment an injured worker receives.
“The medical profession is about lifting up patients for quality of care,” she said. “Quality of care should never be compromised.”
Exploring the return-to-work dimensions of workers’ compensation, Rosenthal explained that it’s important to understand the difference between “impairment” and “disability.” For example, while a torn rotator cuff isn’t usually devastating to most people, the nature of the job could change that perception of severity.
“If it’s a Major League Baseball pitcher, it could even be career-ending,” Rosenthal said.
Keeping the focus on the individual at issue is paramount in good claims resolution.
“The role of motivation is important as it affects severity of injury and the worker’s functioning after an injury,” Rosenthal said. “If they’re not engaging in their care, it could be that something else is going on in their lives.”
In addition to medical knowledge, Rosenthal also shared words of encouragement for those facing what feels like a steep learning curve.
“If you’re new to comp, allow yourself some grace,” she said. “It’s going to take some time.”
Rosenthal also highlighted that the best approach to getting things right in workers’ compensation is to keep it real and make sure that honest information is shared among stakeholders.
“I always want to deal with the truth,” she said.
Apart from that, getting people back to work may be as simple as showing them they matter.
“It’s showing that their employer cares while they are out with an injury that can make all the difference,” Rosenthal said. “People can feel that.”
It’s Simple, Right?
Benton cautioned that every workers’ compensation claim has a potential to reveal challenges no matter how basic the claim appears.
“Every simple claim has the potential to become complicated, and that’s a given,” Benton said. “Workers’ compensation seems formula-driven, but the application rarely is.”
With multiple stakeholders involved in every claim, and no single stakeholder in control of the outcome, what’s the way to better claims resolution and getting workers back to their “normal”?
“Successful claims management requires collaboration and communication,” Benton said. “The role of the employer cannot be emphasized enough because trust is the major factor, and that cannot be stressed enough.”
Timeliness matters too, Benton explained, noting that claims reported on the day of the injury only go to litigation 3.6% of the time.
“For claims reported 15 days or later, that number jumps to more than 42% litigated,” Benton explained. “Timeliness matters because the more time that passes, the more facts disappear.”
Benton also noted that getting people back to work is the best way to get them over an injury.
“Return to work is the most underappreciated return-to-work strategy,” Benton said. “The sooner they head back to the workplace, the quicker they recover, and the longer it takes them, the less likely they are to return to the job.”
Building on Rassp’s comments on litigation, Benton explained that an employee will go to an attorney when they feel alone.
“Why do people retain attorneys?” Benton asked. “They’ll almost always tell you, ‘I felt my employer didn’t care.'”
The answer to that challenge is to focus on communication and engagement.
“Communicate frequently,” Benton said. “Claims don’t get litigated because they’re complex; they become complex because they get litigated.”
What’s the takeaway when a judge, doctor, and claims exec get together to breakdown comp? Communication, trust and early engagement remain the keys to better outcomes.
