Worker’s CompensationThe Rules of the Game

Alice M. Adams, RNMay 14, 2012

ama@alicemadams.com 404-771-5155

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

Commonalities among states

HIPAA

Medical Only vs Lost-Time

What is Workers’ Compensation?

Texas

CaliforniaQME IME DME SSSOP IMR

Georgia

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

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

The IME

When the defense orders an IME

When the claimant schedules an IME

California DME/QME/AME

Does an IME change anything?

What Can You Do?

When you attend an IMEAsk the attorney what he wants

Meet and prepare the patient

Review the records

Provide a summary if requested

A pre-approved silent observer

Know what to expect

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

Why do it?

When the patient may notunderstand or is frightened

When the care is complex

When the physician is unknown

When the physician is known

Confidential Work Product of the LNC

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

Seeing the big picture by looking at the totality of care

When patient advocacy means less care

The case of Mr. Cilantro

Babysitting vs active case management can often lead to iatrogenic complications

Sometimes, NO is in the patient’s best interests

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

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…”

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

Dr. David B. AdamsAtlanta Medical Psychology

• Forgotten appointments

• Last minute excuses & broken promises

• Over-sedation

• Illiteracy

Poor prognosis

Dr. David B. Adamswww.psychological.com

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

What is a WC-3 filing?

Controverted claims and Potential Employer Defenses

Arising out of and in the course of employment

Rycroft analysis

Deviation from employment activities

What Can You Do?

The Controverted Claim

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

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?

Medical Evidence to support “in the course of”:

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

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

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)

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

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/