Misdiagnosis and Reduction of Impact To Workers' Compensation Patients

An article in the Workers' Compensation Outlook (Volume 25, No. 7 - April 2015) discusses the impact of misdiagnosis and incorrect medical treatment. While this is a distinct problem throughout the United States and the world, it is particularly acute in the Workers' Compensation context. The article was written by Bruce Friedman, M.D..

The article quotes the American Journal of Medicine with a statistic, 15% of all medical cases are misdiagnosed. In the United States, the article states that this impacts 12 million people, about 1 in 20 adults, each year according to the British Medical Journal Quality and Safety paper. Further, WCO paraphrases from a Mayo Clinic study that found that, despite in significant advances in modern diagnostic techniques and invasive monitoring, the percentage of missed major diagnoses have not changed in the past 20 - 30 years. This can lead to incorrect procedures, worsening conditions, complications and in far too many cases, death or permanent disability.

WCO states "Perhaps one of the biggest drivers of workers compensation misdiagnoses, however, is lack of access to the right specialized medical expertise - or to specialized expertise at all."

In our business of administering workers' compensation claims primarily for self-insured employers and groups, we addressed this situation more than 10 years ago. After decades of hearing about "best practices" on the medical side of workers' compensation, it was our observation when taking over claims from several of the nation's largest and most well-known TPAs, that some of the worst examples of claims that became complicated (and extremely expensive) were those that were not medically addressed in time to actually help the worker recover and get their life back. The signs were there, but the "best practices" guidelines only allowed the adjusters to involve medical case managers (nurses) in the event of a proven life changing disability or catastrophic injury. In many of the claims that we have taken over, involvement of qualified medical professionals was either not recognized by the adjuster or they were prohibited from involving them due to time constraints (flat rate fee agreements and very high per adjuster file loads) or claim cost budget limitations. WCO states that according to Johns Hopkins University and Hospital "that 40 - 67 percent of chronic pain patients were misdiagnosed by outside doctors." In many cases, including long term chronic pain patients, these costs are near a million dollars per claim. Proper diagnosis and the associated proper, timely medical treatment can result in much better healing AND a savings in the hundreds of thousands of dollars per claim.

To ensure that injured / recovering workers get to the correct specialists as quickly as possible, we utilize RNs on every case, Medical Only or Lost Time, where there are complicating issues. While some might comment (and we've heard the comments from auditors) that this increases the administration costs of each claim, they do not have a reasoning behind why the overall costs of claims that we handle are so much lower than our clients' similar industry peer groups. In one example, we found that over 10 years, one of our clients benefited by a 48% reduction of the full cost of their self-insured workers' compensation program, including the additional cost of our services and those of medical cases managers. This figure is closer to 65% when one factors in benefit inflation and the inflationary pressure of medical costs and the annual fee schedule adjustments.

Involvement of qualified, involved and engaged medical case managers on workers' compensation claims, from DAY 1, not only allows workers' access to the right treatment at the right time, it allows them to recover faster and more completely. And in our experience, a claim for a worker that is fully recovered and back to work is far less expensive than one who experiences a misdiagnosis or incorrect medical procedure. The workers get their lives back, the payer pays out less. It's the right thing to do.