Tag Archives: Predictive Triggers

The Buzz Is Getting Louder


“We know the single greatest roadblock to timely work injury recovery and controlling claim costs. And it’s not overpriced care, or doubtful medical provider quality, or even litigation. It is the negative impact of personal expectations, behaviors, and predicaments that can come with the injured worker or can grow out of work injury.

This suite of roadblocks is classified as “psychosocial” issues – issues which claims leaders now rank as the number one barrier to successful claim outcomes according to the Workers’ Compensation Benchmarking Study’s 2016 survey – and they drive up claim costs far more than catastrophic injuries, mostly due to delayed recovery.”

That’s the beginning of a new White Paper authored by friend and colleague Peter Rousmaniere and Rising Medical Solution’s Rachel Fikes. The Paper, How to Overcome Psychosocial Roadblocks: Claims Advocacy’s Biggest Opportunity, reports on Rising’s 2016 Benchmarking Survey and describes how the workers’ compensation claims management community is ever so slowly coming to realize the leading cause of delayed recovery for America’s injured workers is psychosocial in nature and that efforts to deal with this have, up to now, been woefully inadequate.

Rousmaniere and Fikes point to enlightened employers and insurers who are leading their companies to a greater acceptance of the need for competent, professional intervention to help injured workers overcome mental and emotional barriers delaying their return to employment.

They cite the work of Denise Algire, Director of Risk Initiatives and National Medical Director for Albertson Companies, a grocery chain with more than 250,000 employees. They also report on efforts by The Hartford, Nationwide Insurance and CNA.

All of the progressive actions undertaken by these organizations have one thing in common: the development of an empathic interview methodology devoted to understanding the “whole person” to discover which claims will need more intensive and specialized intervention.

At The Hartford, Medical Director Marco Iglesias reports 10% of claims fall into this bucket, but they consume 60% of total incurred costs. He says adjusters now ask each injured worker an important question: “When do you expect to return to work?” The Hartford’s analytics indicate any answer longer than ten days is a red flag for the future.

Nationwide Insurance, under the direction of Trecia Sigle, VP of Workers’ Compensation Claims, is building a specialized team to address psychosocial roadblocks. Nationwide’s intake process will consist of a combination of manual scoring and predictive modeling, and then adjusters will refer red-flagged workers to specialists with the “right skill set.”

Pamela Highsmith-Johnson, national director of case management at CNA, says the insurer introduced a “Trusted Advisor” training program for all employees who come into contact with injured workers. CNA’s Knowledge and Learning Group helped develop the training with internal claims and nurse staff.

This White Paper adds to the now undeniable research indicating the psychosocial problem is the biggest one facing the workers’ compensation claims community. The leading experts agree that empathy, soft talk and the advocacy-based claims model is the method of choice for helping injured workers whose claims carry a psychosocial dimension. The experts cited in the White Paper all agree that adjusters will require extensive and repetitive training to learn the new techniques.

However, all of this is a heavy lift for an adjuster community overburdened and overwhelmed with work, a group for which the average lost time claim load is often north of 150. Even with better training, they can’t do it alone. To really turn the psychosocial tide will require a well-rounded team of claims adjusters, nurses, case managers and external, well-trained clinicians working together with transparent, technologically advanced communication.

The missing links thus far are those well-trained clinicians and the advanced communication. And that is why Workers Compensation Psychological Network exists.

We have to say, boast really, that it’s nice to get the solid validation found in this compelling White Paper. Writing today from Berlin, where he’s vacationing, Peter Rousmaniere said, “The article was timely and definitively supports your program.”

So, yes, the buzz is getting louder.


Predictive Psychosocial Triggers For Workers’ Compensation Claims

There are a number of factors, which, if present, provide accurate prediction of who will benefit from early psychological evaluation. Current research is conclusive that the two most predictive psychological factors regarding who will file a non-traumatic occupational injury claim are:

  • Job task dissatisfaction; and,
  • Distress as reported on Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI Scale 3 was created using patients who exhibited some physical complaint for which no general medical explanation could be established.

However, employers rarely sense job dissatisfaction in one of their workers and claims adjusters don’t administer the MMPI to claimants before or even after they file claims.

So, when we attend claims association meetings in New Jersey, we are often asked what psychosocial factors, if present in a claim, should prompt a speedy referral for an Initial Psychological Evaluation. With that in mind, and drawing on the best evidence-based scientific research available, we’ve put together a list of specific Predictive Triggers for workers’ comp claims, Triggers which, if three or more are present, indicate early referral for an Initial Psychological Evaluation  is important. Keep in mind that our Initial Psychological Evaluation, although not technically an IME, is done at the IME level.

In no particular order, here are the Triggers:

  • History of abuse, sexual and/or physical
  • Excessive alcohol consumption
  • History of narcotics abuse
  • Depression, or a history of it
  • Coping inadequacy
  • Two or more prescriptions for narcotics
  • Perception of poor health in general
  • Passive attitude
  • Widowed or divorced
  • Tendency to catastrophize and make a referral
  • Blue collar, physically demanding job
  • Complaints of headaches, with no head injury
  • PTSD complaint, without traumatic experience
  • Age over 40
  • Low non-work activity levels
  • History of Somatization (Somatization is the conversion of anxiety to physical symptoms)
  • Driving distance from home to work greater than  30 miles
  • History of filing workers’ comp claims, or other legal claims
  • Poor performance in high school

If you’re a claims adjuster, a nurse case manager or an attorney handling workers’ comp claims, you’ve seen many claims where a number of these Predictive Triggers are present. And you’ve probably been frustrated because the claims have not closed when they should have; they drag on; MMI seems elusive. Workers Compensation Psychological Network can help. Give us a chance. Create an account and login at www.wcpn.net to Make a ReferralSooner – Faster – Smarter.