View this article online: https://www.claimsjournal.com/news/national/2024/08/08/325461.htm
Catastrophic workers’ compensation claims present a complex web of medical, legal and financial challenges.
Professionals need a roadmap for navigating the intricate journey from initial injury through long-term care and potential settlement, with key strategies to improve outcomes in these demanding scenarios. Understanding this lifecycle and implementing best practices at each stage can lead to better medical results, increased worker independence and more efficient claim resolution.
Understanding Catastrophic Claims
Catastrophic claims can arise in any industry, resulting from incidents such as car accidents, falls from heights or even seemingly minor trips and slips. These claims typically involve traumatic brain injuries, spinal cord injuries, serious burns affecting more than 25% of the body, amputation of a major extremity, crushing or massive internal injuries, and partial or total loss of vision in one or both eyes.
Early Intervention and Acute Care
When a catastrophic injury occurs, the employer’s immediate priority is ensuring the injured worker’s safety and facilitating emergency medical response. This includes calling 911 and keeping the injured worker safe from further harm while also ensuring the safety of other personnel nearby. Emergency responders will transport the injured worker to the nearest appropriate medical facility for stabilization. The initial facility may not have the full capacity to manage the medical needs and may preliminarily stabilize the injured work and transfer to a level I trauma center for more definitive intervention.
Once the claim is reported to the insurance carrier or third-party administrator, an experienced claims professional should be assigned to report the claim to any excess carriers, reinsurers, or other stakeholders. A critical strategic decision at this stage is the assignment of an experienced catastrophic onsite nurse case manager.
The role of the catastrophic nurse case manager cannot be overstated. This professional is vital in establishing relationships with the medical treatment team, the injured worker, and their family, while effectively communicating with the adjuster and claims team. Their experience and pre-existing relationships with trauma centers help ensure timely medical updates and improved care coordination. Moreover, their interpersonal skills are crucial in developing rapport with the family, which is key to influencing the next steps in the rehabilitation process, particularly in educating about the benefits of specialized care at a center of excellence.
Specialized Treatment and Rehabilitation
Once medically stabilized, the injured worker may be transferred to a rehabilitation facility for ongoing recovery. This often involves a center of excellence, but in some cases, a short admission to a long-term acute care hospital may be necessary to prepare the worker for intensive rehabilitation.
Centers of excellence play a crucial role in catastrophic injury treatment. These specialized facilities have extensive experience treating specific types of catastrophic injuries and employ a multidisciplinary approach to care. The injured worker’s team may include physicians, nurses, various therapists, psychologists, chaplains, and experts in specialized equipment and mobility needs.
During acute rehabilitation, the goals include educating the injured worker about their condition, strengthening their physical and mental capabilities, teaching skills for managing their condition independently, and training family members and caregivers. This phase prepares the injured worker and their family for eventual discharge back into the community.
Strategic considerations at this stage include early involvement of family members in the rehabilitation process and incorporation of mental health professionals into the core treatment team. These approaches can significantly impact outcomes by providing crucial support systems and addressing psychological aspects of recovery from the outset. Additionally, designating a social worker or similar professional to liaise with the family can be invaluable. This liaison can help navigate the complex emotional landscape, provide resources, and ensure clear communication between the medical team and the family, ultimately contributing to a more holistic and effective recovery process.
Transition and Long-Term Care Management
As the injured worker progresses, planning for the transition home or to a long-term care facility begins. This process involves comprehensive home modification assessments, coordination of specialized equipment and supplies, arranging appropriate attendant care, and addressing ongoing psychological and emotional needs.
The ultimate goal is to place the injured worker in the least restrictive environment that meets their medical and care needs. Ensuring the injured worker can access their home environment is crucial for safety, maximizing independence and reducing caregiver burden and medical complications.
Home modifications may range from simple changes such as ramps and grab bars to extensive remodels or even building a new home. The process begins with a home assessment to determine the scope of necessary modifications. For renters, alternative housing options may need to be explored.
Attendant care is also an important variable in the return to home. Care needs can range from unskilled personal care attendants to more skilled nursing care (CNA, LPN, RN) services. Unskilled care is appropriate for injured workers who may require some assistance with activities of daily living or supervision. Other injured workers who may have tracheostomies, feeding tubes or require bowel and bladder programs will require some skilled nursing care at home. When addressing the level of home care needs, it is important to be specific with the level of care and hours of care. This may be provided through home health agencies or family members.
For those unable to return home, finding appropriate long-term care facilities becomes the priority.
Stakeholder Collaboration and Best Practices
Effective management of catastrophic claims requires close collaboration among all parties involved in the injured worker’s care and recovery. This includes medical professionals, rehabilitation specialists, the employer and insurance representatives. Regular communication ensures everyone is aligned on the injured worker’s care plan and progress.
Throughout the claim process, it’s important to stay actively involved and informed. This may include periodic reviews of the treatment plan, discussions with medical providers and keeping the injured worker and their family updated on progress and next steps.
Claim Resolution and Cost Management
As the claim progresses, settlement considerations may arise, involving careful evaluation of opportunities, addressing Medicare Set-Aside requirements, and balancing long-term care needs with cost management. Professional administration of Medicare Set-Asides with consideration for annuity funding with reversionary provisions are options to be explored that can make settlement of these catastrophic and costly claims more viable.
When approaching settlement, consider the following:
By implementing this approach, significant improvements in outcomes for injured workers can be achieved while effectively managing long-term costs. The goal is to balance specialized care, stakeholder collaboration, and strategic long-term management throughout the injured worker’s journey.
Charting a Course for Success
By implementing this comprehensive, stage-based approach to managing catastrophic workers’ comp claims, significant improvements in outcomes for injured workers can be achieved while effectively managing long-term costs. The key lies in maintaining a balance between specialized care, stakeholder collaboration and strategic long-term management throughout the injured worker’s journey. This approach not only benefits the injured worker but also helps manage the significant long-term costs associated with catastrophic claims, leading to better medical results, increased worker independence and more efficient claim resolution.
Waltz is a senior national catastrophic claim analyst at Midwest Employers Casualty, a Berkley Company. Waltz has more than 19 years of experience with workers’ compensation claims management.