Worker’s compensation 05.09.12

Worker’s CompensationThe Rules of the Game

Alice M. Adams, RNMay 14, 2012

[email protected] 404-771-5155

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Define the parameters of an accepted work-related injury and the employer’s possible defense to that injury.

Identify the nursing role in attending IME appointments with patients and assisting attorneys with controverted claims

Careers in Legal Nurse Consultingwww.lncConference.com

Saturday July 21, 2012

Objectives

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Commonalities among states

HIPAA

Medical Only vs Lost-Time

What is Workers’ Compensation?

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Texas 4

CaliforniaQME IME DME SSSOP IMR

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Georgia6

General Concepts

• What is workers’ compensation• When does coverage begin• What is considered an injury• Report within 30 days, file within one year• Horseplay, haste and inattention• Exclusive remedy• Lawsuit/subrogation lien• Lawyer fees• Loss of benefits 7

Employee’s Responsibilities

1. Report within 30 days2. Accept treatment & rehab3. RTW, reduced earnings, compensation4. Job attempt5. Statute of limitations6. Drug test refusal7. False and misleading statements

http://www.files.georgia.gov/SBWC/Files/employee_handbook.pdf

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What might rouse the suspicions of an employer?

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What is an IME?

An IME is an opportunity to have a different doctor physically examine an injured worker and review their medical records and diagnostic tests for the purpose of providing a second opinion. The IME doctor should make a diligent effort to address some of the issues the patient is having and try to figure out what is or is not going right medically speaking. He or she may also address the injured worker's current work restrictions, treatment options, the necessity of a recommended surgery, and when applicable, the injured worker's permanent partial disability rating if one has been issued.

http://www.georgiaworkerscompensationadvocate.com

QME IME DME AME PME SSSOP IMR

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1. When I find a client's diagnostic tests are consistent with a serious injury… but the treating physician is skeptical of the employee's complaints.

2. When my client is doubtful of the diagnosis, treatment options, or work restrictions, I will recommend an IME for the sole purpose of addressing my client's concerns.

3. When my client has an unusual condition such as Complex Regional Pain Syndrome, and an expert is required for a diagnosis or treatment plan.

When does Bryan S. Hawkins, Pltf Atty, request an IME?

http://www.georgiaworkerscompensationadvocate.com11

What Can You Do?

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Why would you attend an IME?Ask the attorney what he wants

Meet and prepare the patient

Review the records

Provide a summary if requested

A pre-approved silent observer

Chart what is said and done, wait times, staff and physician attitude

When the patient may notunderstand or is frightened

When the care is complex

When the physician is unknown

When the physician is known

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Confidential Work Product of the LNC who is hired by the plaintiff attorney

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Duties of the Case Manager

• Medical Management• Vocational Evaluation• Identifying medical or return to work issues• Job descriptions• Medical Cost Analysis• Communication with medical providers to clarify

treatment plans

Zan Lanford, RN,CCM, Wright Rehabilitation Services

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Seeing the big picture by looking at the totality of care

When patient advocacy means less care

The case of Mr. Cilantro

Loss of objectivity can lead to iatrogenic complications

Sometimes, NO is in the patient’s best interests

Remember the campfire game of whispering into each others’ ears?

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Psychological Complications

When is care allowedWho makes the call

What is usual and customaryWhat about pre-existing

from Mr. H. Dill Battle, III of Spillman Thomas & Battle, PLLC

http://www.workerscompensation.com/compnewsnetwork/workers-comp-blogwire/14043-wv-sca-secondary-condition-psychiatric.html

http://www.spilmanlaw.com

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Patients vs. Injuries

Dr. David B. Adamswww.psychological.com

“it is often more important to know what type of patient has the injury

…rather than to know what type of injury the patient has…”

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My 10 Critical Diagnostic Data – All Pain Patients

•The Patient’s Developmental History•The Patient’s Educational History•The Patient’s Medical History (including addiction)•The Patient’s Work History•The Patient’s Recounting of the Accident•The Patient’s Understanding of the Physical Damages•The Patient’s Assessment of Medical Care•The Patient’s Expectations and Future Goals

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• Forgotten appointments

• Last minute excuses & broken promises

• Over-sedation

• Illiteracy

Poor prognosis

Dr. David B. Adamswww.psychological.com 20

Identifying Depression

1. Has patient lost or gained significant weight?2. Is there a specific sleep problem?3. Is the patient irritable?4. Is the patient forgetful, have difficulty concentrating

and/or have trouble making decisions?5. Does the patient feel guilty and/or worthless?6. Is the patient readily tearful?7. Has the patient ceased to enjoy hobbies or interests?8. Is there a decrease in libido?9. Is there psychomotor agitation or retardation?10. Does the patient express thoughts about death?

Dr. David B. AdamsAtlanta Medical Psychology 21

What is a WC-3 filing?

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Controverted claims and Potential Employer Defenses

Arising out of and in the course of employment

Rycroft analysis

Deviation from employment

Intoxication /Fighting/Horseplay/Suicide

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What Can You Do?

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The Controverted Claim

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1. Is the condition an actual “injury”?2. Did it occur in the course of employment?3. Did the injury arise out of employment?

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Angina (caused by disease, worsened by exertion, involves no death of tissue) is more of a recurrent symptom vs Myocardial Infarction (an acute MI involves actual death of tissue and actual damage

TIA (ischemic, resolving within 24 hours)vsCVA (80% ischemic, 20% hemorrhagic)

Disease vs Injury -What’s the Difference?

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Medical Evidence to support “in the course of”:

-serum enzyme changes (time-specific)-EKG-nonspecific indices of polymorphonuclear leukocytosis-cardiac imaging

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Arising Out Of……….But For

“There must be some causal connection between the conditions under which the employee worked and the injury which he received.”

And

“The cause of the injury must be incidental to, rather than independent of, the employer-employee relationship.”

Time matters – the shorter the interval, the stronger the case for causation

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How hard was the patient working?

It may not matter. Georgia is not among those states which require that the job-related physical exertion be an unusual one. The plaintiff could have even been doing lighter than usual work that day.

In the Georgia Laws, 1963: P. 141: the heart attack can be “…attributable to the performance of the usual work of employment”

But, awards have been upheld when undue emotional stress precipitated a cerebral hemorrhage.

Another was upheld when the cerebral hemorrhage was due to his working when it was unusually hot (rather than to his drinking iced tea).

What matters: Drawing the line between a noncompensable heart disease that manifests itself at work, and a compensable heart injury to which the job exertion was a contributing factor”(Guye v. Home Indemnity Company, 141 Ga. 213, 244, S.E.2d 864(1978)

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So…What Can You Do?

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www.psychological.comDiagnoses, Forums, Workers’ Comp. Blog & Online Referral

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http://blog.reduceyourworkerscomp.com/2010/04/know-the-difference-between-lost-time-and-medical-only-claims-shades-of-gray/#axzz1uO8kesDS

http://www.georgiaworkerscompensationlaw.net/denial_of_claim_based_on_inacc.html

http://www.dir.ca.gov/dwc/

http://sbwc.georgia.gov/portal/site/SBWC/

http://www.tdi.texas.gov/wc/index.html

www.psychological.com

http://www.nursingworld.org/Research-Toolkit

http://www.guidelines.gov/

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