Accommodating Medically-Imposed Work Restrictions

Unfortunately, even with the best efforts to prevent workplace injuries, employees may still get hurt and then the medical provider may impose a work restriction that temporarily limits their activities. For many employers this appears to be a situation in which they have few to no options; however, there is still an opportunity to control the cost of this workers’ compensation claim, but it requires action on the part of the company. That action is known by many names – modified duty, light duty, early return to work programs, even restricted duty. Regardless of the name, the objective is the same and that is to accommodate the medically-imposed work restriction. Using modified duty is not easy. It will require time and effort. It sometimes involves shuffling the job duties of others or trying to create productive work for the injured employee out of thin air. It may even require that training be conducted for one or more employees to perform tasks that they have never performed before. However, the benefits of doing so are numerous. This newsletter describes them as well as addressing some of the common objections for not doing so.

Financial Advantage Benefit – A portion of the cost of workers’ compensation insurance claims includes the payment of temporary total or partial disability. This payment is better known as lost wages. Ironically, that descriptive phrase applies more to the employer losing wages as opposed to the employee losing wages because it is payment for “not working.” Initially this payment is made by the insurance provider, but in the long run the company will ultimate pay for it through increased insurance premiums, so it can really be said that the company is making the payment for an employee to not work. Read that phrase again – the company is making the payment for an employee to not work. That just does not make good financial sense. What is the other option? Accommodate the medically-imposed work restriction. There are two definite advantages for doing so. It will reduce or eliminate the lost wages portion of the claim, thus reducing the cost of that claim and in turn reducing the negative impact on your future workers’ compensation insurance premiums. In addition, if you utilize (accommodate) an employee who has a medically-imposed work restriction then it stands to reason that the organization is benefiting from his/her contribution to the productivity of the company.

Fraud Prevention Benefit – A common fraud involved with workers’ compensation claims is the use/abuse of medically-imposed work restrictions. The less than honest injured employee will “work the system” to ensure that work restrictions are written by the medical provider in order to stay at home/away from work. This affords the employee several opportunities to do anything, from painting the house, to going turkey hunting, to even picking up a second job and making extra money while not working the primary job. Accommodating a medically-imposed work restriction will get that employee back to work, unless he/she refuses to do so and then the insurance provider has the option to stop the wage replacement payments. Besides that, accommodating the work restriction will bring the employee back to work and back to formal supervision, which ensures that he/she will not violate the medically-imposed restrictions, at least for the time that he/she is at work.

Holistic Healing Benefit – For whatever reason, experience has shown that injured employees heal quicker when they are allowed to return to work. This can be attributed to the fact that their self esteem improves because they feel productive, or they benefit from the social aspects of time spent with co workers, or their personal routine remains relatively unchanged. Regardless, injured employees who are allowed to return to work as soon as possible heal quicker. The obvious conclusion then is to accommodate medically-imposed work restrictions to speed the recovery process.

Workforce Morale Benefit – As stated above, injured employees’ self esteem will improve because they feel productive and when their self esteem improves so does their morale. In addition, they receive the message that management is willing to make the extra effort to accommodate a medically-imposed work restriction because the employees are valued not only when they are at 100 percent, but also when they are not physically up to par. Then what about the balance of the workforce – how does accommodating medically-imposed work restrictions benefit their morale? Their morale is heightened by accommodating medically-imposed work restrictions because they are not asked to take up the slack for a co worker who is off work.

Some employers object to the use of modified duty, light duty, early return to work programs, or restricted duty. Two of the more common objections are based upon myths. A third reason is simply a lack of management motivation.

Objection #1 – Injured employees who are allowed to return to work and perform modified duty are more likely to get hurt, thus resulting in another workers’ compensation claim or even a lawsuit. Initially, this sounds like a valid excuse, but consider two facts. Medically restricted employees are performing specific jobs and tasks designed for their restrictions with proper training, equipment and supervision, just like any other employee. Why are they more likely to get hurt? And if they do sustain another injury or aggravate the current injury then workers’ compensation insurance is the remedy. By the way, if they are properly trained, equipped and supervised they are no more likely than any other employee to sustain an injury- so where is the logic behind this objection?

Objection #2 – Many employers believe that using modified duty will create morale problems with other employees. They believe that employees will see a peer performing “light duty” work and view him as getting off easy and not pulling his fair share of the load. This mindset is quickly and easily reversed when disgruntled co workers are assisted in visualizing the alternative, in which the injured employee is off work, makes roughly the same amount of income and does nothing to help get the work done.

Objection #3 – Accommodating medically-imposed work restrictions is just too much trouble. Granted, it does increase management’s workload, but the benefits of using modified duty outweigh this increased workload. Modified duty is a very simple process. No lengthy policy is needed; no forms are required. It simply takes knowledge of the tasks performed by employees (supervisors should know this in their sleep), a general idea of the physical requirements to perform those tasks and a commitment to cash in on the benefits that modified duty provides.

If you don’t want the hassle of accommodating medically-imposed work restrictions, then don’t let employees get injured! However, if they do get injured put on your thinking cap and devise a modified job that will allow them to return to work until their medical restriction is withdrawn. The company will benefit in numerous ways.

Identifying Workers’ Compensation Fraud

 

 

In conjunction with preventing workers’ compensation claimant fraud, an employer must also remain alert for the indications of claimant fraud. Sometimes even the best efforts to prevent the theft are thwarted, so vigilance is necessary. This newsletter describes some of the most common “red flags” of claimant fraud. There are many more.

Prior to discussing those indicators, it is important to understand the impact of claimant fraud. Primarily it is financial, and it is the company that ultimately sustains the loss. For example, when an employee is medically restricted from working he is just that – not working. The company is minus one producer. (By the way, this is true whether the claim is valid or fraudulent.) Next, your workers’ compensation insurance premium will eventually rise simply because your loss history contains a claim. And the often unrecognized financial impact on an organization is the diminished employee morale. Nobody likes to work with a thief, especially a successful thief. Another negative impact that claimant fraud has on an organization is that it subtly changes the employer’s opinion of workers’ compensation insurance and anyone who files a claim. This results in the employer being resentful towards the system (the very institution that exists to cover his losses) and towards all employees who file a claim. This is unfortunate because 99% of workers’ compensation claims are valid and what this disillusioned employer is doing is stereotyping honest people as being dishonest.

Red Flag #1 – Injury Reporting: If an employee reports an injury early on the first day back to work after a weekend or vacation, then the claim may be fraudulent. Most likely the injury occurred during his time off. Also, if there is a significant time lag between the when the employee says the injury occurred and when he actually reported the injury, then the claim may be fraudulent. The advantage to late reporting is that the company has limited opportunity to investigate the facts/evidence surrounding the accident; therefore, its validity really can’t be substantiated. Keep in mind that some injuries are slow to manifest pain, so the employee may be telling the truth.

Red Flag #2 – Statements from Coworkers: If other employees report to management that the claimant is not telling the truth, listen to them. Often times the fraudulent claimant will brag about his deed or confide with another employee prior to submitting the fraudulent claim. In addition, the coworkers may even see the fraudulent claimant in the community performing tasks that are inconsistent with his medically restrictive injury (loading groceries into the trunk of his car; cutting his grass with a push mower; performing repairs to his property; going hunting; etc.).

Red Flag #3 – Accident Description: If the “allegedly” injured employee has difficulty recalling the details surrounding his accident, or if those details change with each recounting of the event, then the claim may be fraudulent. It is more difficult to consistently lie than it is to tell the truth.

Red Flag #4 – Employment Status: If the claim is reported by an employee who has limited tenure with the company, or who may be facing layoff, then the claim may be fraudulent. The primary motivation for fraudulent claims is to receive medical work restriction, which then affords the individual the opportunity to unofficially work elsewhere and to increase his income. On the other hand, if an individual is facing imminent furlough then he may do the math and realize that a workers’ compensation claim may be financially more advantageous than unemployment benefits.

Red Flag #5 – Personal Financial Pressures: If the employee who files the claim is experiencing tough financial issues in his personal life, then the claim may be fraudulent. Unfortunately, several individuals experience financial crises and they “cross the line” and resort to desperate measures to survive. Workers’ compensation fraud is one measure. Add to this the fact that many employees do not truly understand the workers’ compensation system. They believe it is an entitlement; therefore, they do not view themselves as a thief if they submit a fraudulent claim. Lastly, many Americans do not have private health insurance, but they do have workers’ compensation insurance. The choice seems clear, even if it is stealing.

Red Flag #6 – Evasive Behavior: If the medically restricted employee avoids contact with the company or otherwise seems evasive, then the claim may be fraudulent. This evasiveness is usually characterized by the employee providing a P. O. Box for his address instead of a physical location. It’s difficult to visit someone at a post office box. And if the employee never answers his phone then you begin to wonder about his whereabouts and his “doings.”

Red Flag #7 – Personal Attitude: If the employee demonstrates a persistently negative or defiant attitude regarding the injury or the claim, then the claim may be fraudulent. Sometimes employees will “settle the score” with an employer by filing a fraudulent workers’ compensation claim. If there have been other integrity issues with this individual during his employment, there may be strong reason to suspect that a suspicious injury is also less than honest.

Red Flag #8 – Personal Ties: If the employee has close ties to others who have defrauded the system or others who may currently be off work for any reason, then the claim may be fraudulent. In the first situation an employee may be influenced by his friends who have been successful in submitting fraudulent claims. In the latter, an employee may be motivated to get off work, regardless of the method, so he can be available when relatives come to town for a visit, or when his spouse is off work. These are often known as “sympathetic claims.”

Red Flag #9 – Legal Expertise: If the claimant demonstrates an unusual knowledge regarding workers’ compensation or retains an attorney soon after filing the claim, then the claim may be fraudulent. Both of these situations are very strong indicators of fraud. Most employers have limited knowledge of the workers’ compensation system so why would an employee be well versed in its intricacies? Furthermore, the system is designed to minimize litigation so what is the true motivation for retaining an attorney so early in the process? Perhaps it could be to “bully or bluff” the employer and insurance company into an early settlement.

Red Flag #10 – Medical Treatment: If an employee fails to attend medically prescribed physical therapy sessions or follow-up evaluations, or even changes doctors just prior to the termination of his medical work restriction, then the claim may be fraudulent. These actions, or inactions, on behalf of the employee/patient represent intent to prolong the medical treatment process in order to prolong the time away from work (temporary disability = pay check without work).

As stated in the March 2008 newsletter, the employer is in the best position to prevent, identify and then control claimant fraud. This is best accomplished by establishing and enforcing company policies, educating employees, investigating accidents, documenting events and reporting this information to your insurance claims adjuster. Workers’ compensation claimant fraud is a significant obstacle to business profit and sometimes even survival.