EXECUTIVE SUMMARY

One strategy for resolving workers’ compensation claims as quickly and optimally as possible is to assemble a medical roundtable of professional experts to review claims.

• The roundtable experts can discuss the types of medical issues that drive claim complications and require multifaceted solutions.

• Case managers can be involved in claim review, helping with social determinants of health barriers and providing practical guidance on getting patients back to work.

• The roundtables can take place over conference calls, covering 10 to 15 medically-complex claims, including cases that have certain types of injuries or medication issues, such as opioid addiction.


Medical expenses are the chief drivers of expenses in workers’ compensation claims, fueled in part by patients with multiple medications and comorbidities.

“We recognize more and more that medical complexity drives activities and outcomes on a claim,” says J.J. Schmidt, MBA, PhD, senior vice president and head of analytics and innovations at York Risk in Jersey City, NJ.

“When someone has a workers’ compensation injury, we want to get that person back to the state they were in before they had their injury,” he says.

This is why it is important to seek guidance from medical professionals, he adds.

“We need to pull in medical experts to advise and guide the direction of those claims,” Schmidt says. “What we’ve seen is that pulling in medical experts serves a couple of purposes.”

Physicians, nurses, psychologists, and others can educate and share information on cases. Workers’ comp claim adjusters can use the medical roundtable model to access their expertise.

“When you’re doing rounds in a hospital, the physician and residents will go around and talk about what’s going on with patients and what we need to do and what are the challenges,” Schmidt says. “We can borrow those same concepts and deploy the grand rounds into a claim or administrative setting.”

The typical claim review might involve adjusters and their clients meeting remotely to go through dozens of open claims. They would look at claims that had been open for six months or a year and talk about why it was still open and what kind of progress is being made in resolving the claim, Schmidt explains.

“What we started to recognize is that so many things that were obstacles or challenges on a claim were medical issues,” he says.

For example, a patient may be unable to undergo surgery due to diabetes, hypertension, and medication.

“Or, this person has been on opioids for nine months or a year, and it’s stalling the progress of getting this person back to work, or they can’t do surgery because of obesity issues,” Schmidt says.

These kinds of medical issues were driving claim complications. The solution was to meet with a medical team that could include a physician, psychologist, pharmacist, and clinical program manager.

“An adjuster will present this claim, and then we talk about it, and a medical team is able to give some advice,” he says.

Case managers also can be involved in claim review. “For many case managers or case management companies, this is something they could be doing,” Schmidt adds.

Case managers can help with social determinants of health barriers and provide an all-encompassing perspective on what it might take to get a patient back to work, he says.

“Nurses and case managers have a unique perspective on these medical issues, and I think that these issues are forgotten, sometimes, on the claims side of things because adjusters are trained to be adjusters — not medical professionals,” Schmidt explains.

Here is how the medical roundtable can work:

• Assess caseload. Medical roundtables can be held via conference or video call.

“We have claims in different states and offices, so we usually do it virtually,” Schmidt says.

A first step is to identify 10 to 15 medically complex claims.

“We tell clients we’re going to do this medical roundtable, and we ask, ‘Which are the files you want us to include based on medical complexity factors?’” Schmidt says. “We put those files together.”

The roundtables also could be used for cases involving certain types of injuries or when workers experience medication issues, such as opioid use.

When injured workers use opioids and exceed a high threshold of morphine equivalent dosages (MEDs), then the claim adjuster might ask for solutions from a medical roundtable. People taking high dosages of opioids might forget they have already taken their pills and take more, or they might think it is OK to drink a glass of wine and not realize that it could increase their risk of complications.

Case managers can call these patients to make sure they know the risks of taking high dosages of opioids and to reinforce that they should not drive or drink alcohol, he says.

Ideally, physicians tell patients of opioid risks, but some injured workers might not have been to a doctor in four or five years or they have not become comfortable with their doctor.

“When you have that situation, often there is not a level of trust between the injured worker and the physician,” Schmidt says. “In discussing these claims in roundtables, we might say, ‘You know, this might be an opportunity to hire a nurse to provide patient education.’”

• Review, summarize, discuss, and take action. The medical roundtables include the claims adjuster, sometimes a unit manager, and the medical team. A case management company and pharmacist also can be involved, and the employer might weigh in on the discussion.

Before the meeting, the adjuster writes a short summary that is sent to everyone on the medical team, so they are prepared when the discussion begins. The summary includes the case challenges, demographics, and other issues, Schmidt says.

“When our medical director looks at the file, she looks at challenges, notes, claims files, virtual table, and physical table, and is ready to discuss everything,” he adds.

Each person reviews the cases that will be discussed over the course of the one- to 1.5-hour meeting, Schmidt says.

“We talk about settling the claim and see if we can close it,” he says. “We want an action plan when we’re finished.”

The adjuster makes the action plan part of the claim strategy and executes the plan.

• Include case management expertise. Case managers help adjusters understand the solutions they can provide, Schmidt notes.

For instance, case managers can talk about patients’ medications and complications. They can talk about social determinants of health solutions, he says.

“Case managers are more in tune with translating those things to help the adjuster understand how those factors can complicate a claim or add to the challenges on a claim,” Schmidt says.

For many people, the medical process is very complex. They do not interact with healthcare systems very often, nor do they have someone who can advocate for them, he says.

When the adjuster wonders why the patient did not follow their medical instructions, the case manager might be able to explain how the patient didn’t graduate from high school and doesn’t understand the medical terminology, he adds.

Case managers bring value to the table. They can be advocates who help patients and guide them through the healthcare system, Schmidt says.

“We need to adapt to the changing nature of claims administration and recognize that it’s the medical components driving it,” he says. “We need medical resources, like nurse case managers, available and able to assist and move these claims along and be part of the team.”