In Depth: Workers' Compensation

When Claims Go Off the Rails

Case managers and pharmacy benefit managers are key pieces of the puzzle for payers trying to rein in catastrophic claims before they’re too far gone.
By: | November 2, 2016 • 6 min read

When a worker faces the rest of his life in a wheelchair or is relearning how to tie his shoes, most people wouldn’t be surprised if he battles anger, depression and maybe opioid abuse. But why do some people move on after a catastrophic injury and others do not?


And why, after a garden-variety ankle sprain, can most workers return to work quite quickly, while 10 to 20 percent of them descend into a lifetime of unrelenting pain and disability?

“True catastrophic injuries” are medically very different from “migratory” or “creeping” claims, like the ankle sprain that devolves into disability.

Michael Coupland, a psychologist, rehabilitation counselor and network medical director with the IMCS Group, said a large body of data suggests that both creeping catastrophic and “runaway” catastrophic claims are characterized by complicated recoveries, higher costs and more medical complications when the patient presents with one or more of these psychosocial risk factors:

  • Tendency to catastrophic thinking.
  • Guarding or fear avoidance behavior.
  • Perceived injustice and disability mind-set.
  • Adverse childhood events, which weaken the immune system.
  • Psychological comorbidities.
  • Stressors and weak family and social supports.
  • Abdication of control.
  • Lifestyle and demographic risks.

Predictive modeling has advanced to the point that these factors can be identified and acted on earlier, said Dr. Michael Choo, chief medical officer, Paradigm Outcomes.

Once these factors are identified, Choo said, claims managers can put into place the necessary support systems and work with the injured worker to gradually ease them into a more productive recovery.

Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group

Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group

Behavioral therapies are also part of the protocol for traumatic brain injuries, said Zack Craft, vice president, rehab solutions with One Call Care Management. He said brain injuries predictably produce personality changes, including angry outbursts.

The frontal lobes, the part of the brain most vulnerable to injury, are the emotional control center and home to personality, according to the Centre for Neuro Skills. Damage can affect motor function, problem-solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior.

In a historical departure, carriers have started to pay for behavioral therapy in migratory claims, said Maddy Bowling, principal, Maddy Bowling & Associates Consulting. “Payers had suspected malingering in migratory claims and were reluctant to pay for psychological treatments,” but they now assume motivational or psychological problems and recognize that these therapies could be helpful.

Chronic Pain Management

About two weeks after an injury, workers take a pain-screening questionnaire, scored from one to 10: How would you rate the pain that you have had during the past week? In your view, how large is the risk that your current pain may become persistent? A high score, said Coupland, predicts a high chance of chronic pain and delayed recovery.

“We don’t tell patients our goal is to get them off drugs. We say, ‘This is a way to manage your pain.’ ”  — Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group.

In March 2016, the Centers for Disease Control called the nation’s prescription drug epidemic a “doctor-driven crisis” and offered new, non-binding prescribing guidelines. More doctors are weaning their patients from opioids and seeking non-pharmaceutical techniques to help them manage their pain.


Predictably, Coupland said, patients who satisfy any or many of the identified risk factors are fearful of separating from their painkillers and of the debilitating pain that led them to opiate use in the first place. Most are not addicts, and most are compliant patients, following doctor’s orders perfectly.

Still, Coupland said, “getting off opioids is hard,” typically triggering depression, anxiety and withdrawal.

“We don’t tell patients our goal is to get them off drugs,” he said. “We say, ‘This is a way to manage your pain.’ ” He then introduces non-pharmaceutical techniques such as cognitive therapies, biofeedback or hypnosis.

“We have the patient say, ‘I can cope with my pain.’ When the brain hears that, even if the patient isn’t convinced, the words can stand down the stress arousal response, which is a pain generator.”

And he develops a weaning plan with the patient’s doctor. “We set a goal: Get pain down from an 8 to a 5 or 3. Even an 8 to a 7 is fine.”

Role of Pharmacy Benefits Management

Catastrophic injury claims are complex, with multiple providers prescribing multiple drugs, including painkillers.

Phil Walls, chief clinical officer, myMatrixx

Phil Walls, chief clinical officer, myMatrixx

A profusion of medications can cause a “cascade” effect, said Phil Walls, chief clinical officer, myMatrixx.

The appropriate response, Walls said, is to reduce the drug causing the original problem, especially opioids. “They cause drowsiness. We see Ritalin, amphetamines, and other stimulants to counter the drowsiness.” Those in turn may cause sleeplessness, jitters or dry mouth, which could be addressed by yet another medication.

If the prescribing practices — such as dosages, possible drug interactions and duration of the prescription — fall outside guidelines published by the CDC and other health organizations, Walls may contact the prescribing physician.

Do they resent the interference? Not often, he said.

“Medical schools teach collaborative care. They’re taught to embrace interaction when other providers reach out to them.” Even when they give attitude, the post-intervention data Walls monitors shows they make the change anyway 79 percent of the time.

Using their data on providers, types of drugs, dosages and duration of a prescription, pharmacy benefits managers are in a unique position to identify trigger points where an intervention would benefit a claim, said Nikki Wilson, pharmacy product director, Coventry Workers’ Comp Services.

Regrettably, claims often have problems by the time pharmacy benefits managers get involved, she said, especially when the pharmacy benefit is a stand-alone product.

“Medical schools teach collaborative care. They’re taught to embrace interaction when other providers reach out to them.”  — Phil Walls, chief clinical officer, myMatrixx

Multi-product managed care organizations have access to more information about the patient’s and the claim’s history than stand-alone providers. Their risk models may trigger early alerts to potential issues.

For example, “the first opioid prescription we fill will trigger outreach to guide the claim to the best outcome,” Wilson said.

A Minor Claim Gone Awry

All claims require management, but not all runaway claims involve excessive pain or medications.

Eighty percent of excess carrier costs derive from migratory claims, said Zack Craft of One Call. He recalls a claim One Call inherited for a restaurant manager who rolled his right ankle on an oil drip on some stairs.

“He went to an urgent care center, then an ortho group, which gave him an orthotic shoe and a brace, and sent him home.”

That should have been the end of the story, but the man wore the hard orthotic shoes more than prescribed and developed a blister.

“Now he had a wound that didn’t heal right, and then he was diagnosed with diabetes.”

After a stay in the hospital with his foot elevated, he developed foot drop — a gait abnormality — which required more orthotic shoes.

And then he suffered a wound on his left ankle, which he neglected. That resulted in another hospital stay, with an almost 100-pound weight gain from inactivity, poor nutrition and medication. After more than a year, with a degrading condition, he underwent an above-the-knee amputation.

“Now he was into prosthetics, and the weight gain forced him into a power chair,” Craft said. His rental home required a ramp for the power chair, and he went on disability.


“It’s good practice for a case manager to step in when a symptom like an unhealing blister emerges,” said Bowling, which could (and did) indicate a more serious condition.

A case manager could work with doctors on diet and exercise to control weight and avoid the abnormal gait and stress fracture.

“Field case managers go to the physician’s office with the patient, help with referrals, and meet with the family to make sure they understand the treatment plan and their role in compliance,” she said. &


R10-1-16p40-42_3Catastrophic.inddFacing the Unthinkable: What happens in the hours, days and weeks following a sudden, disabling injury?


R10-15-16p38-40_4Catastrophic.inddRoad to Recovery: When it’s time to send patients home, there are new challenges to tackle, for both patients and payers.


Man on wheelchairCreeping Catastrophes: This final story of the series focuses on “creeping” catastrophic claims.


Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.


That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.


Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]