Part 2 of a 2 part story looking into a real life regular “Joe” Workers Compensation saga.
Let's Voice ...
Workers Compensation Permanent and Stationary.
Case Study:
WC : Is it really worth it?
From Part 1, we learned that:
Due to a work related injury, Joe had spinal fusion at level L4, L5, and S1.
The Court ordered compensation for his injury and future medical.
He was deemed Permanent and Stationary and 40% disabled by his doctor.
We learned that a three (3) year long lack of responsiveness (Ghosting) by the Worker's Comp provider caused Joe to not only have to use his own, high deductible, medical insurance to cover the costs of treatment, but was now in so much pain that he was only getting 3-4 hours a sleep at night, best case. This affected both his home and his work life.
It took an attorney to call and get the Workers Compensation provider to finally answer Joes pleas for help.
Spinal injuries, their complications and lasting adverse effects vary from patient to patient. Just do a search for Spinal Fusion and you'll be overwhelmed with results and plenty of advice as to why we should take care of the only spine we have for as long as we can.
Back to Joe:
During Joe's three (3) year period of being ghosted by his WC Insurance carrier, Joe went to a Pain Management specialist and began a journey of treatment: Physical Therapy, Trigger Point Injections, Epidurals at multiple levels, bi-lateral Sacrum-Ilium (SI Joint) Epidural injections and other pain management procedures all covered by his normal health insurance. In addition to the injections, Joe was put on multiple types of medications to help suppress the pain; including several opioid. Though they worked for a period of time, the medications had to be swapped with other, more powerful ones to help relieve the pain. Joe now "needs" these medications just to be able to lead what is now his "new normal."
In the study, “Suicide and drug‐related mortality following occupational injury,” published in the American Journal of Industrial Medicine, researchers found that workplace injury significantly raises a person’s risk of suicide or overdose death. Earlier studies have shown that injured workers have elevated rates opioid use and depression. In fact, depression is among the most well-documented health consequences of workplace injury.[4][5][6] |
Alarming thing about the Workers Compensation System; it's a convoluted and complicated system of requests and denials that must be dealt with just to get treated for an injury. The average "Joe" will not be able to navigate the system on their own! According to a 24 year veteran at the Workers Compensation Appeals Board (WCAB) that I spoke with, "... it's the job of the workers compensation insurance company to keep as much money for their clients as they can; regardless of the pain and suffering the worker is going through."
In the last year alone, there were approximately 10,200,000 results posted on the web regarding Workers Compensation system ...
make that 10,200,002 !
Now that Joe's WC Insurance carrier is on board, they require all medications and procedures (everything) to be submitted on a Request for Authorization (RFI) to the WC Insurance provider. This is a process called "Utilization Review" (UR) and must be done before any treatment can be administered by the doctor and paid by the WC Insurance carrier. One such procedure for Joe that was submitted to the WC provider took over 30 days for the UR to deny it. Like being ghosted for three years, receiving the denial seemed to be par for the course for Joe. But they did approve the opioids.
"It has been determined that the requested medical treatment listed does not meet the established criteria for medical necessity therefore is denied," was what was communicated to Joe and his doctors. By the way, this is the same treatment Joe received months earlier and approved by his own insurance company and is now in need of being repeated.
Now what? Appeal the denied procedure. Another 30 days passes and Joe and his doctors receive yet another denial letter stating the same as above. However, this time, the denial letter also states;
"Chronic pain guidelines do not support endless treatment and
focus on pain at this point in plateau is counterproductive."
Treating pain is counterproductive? What's more disturbing is that they approved the cost of all of the prescribed opioids as part of the treatment. Joe was devastated. How can anyone who has not seen Joe deem him to be in "plateau?" What does that mean to Joe who is medicated on opioids, depressed, and can barely sleep at night? Even though the court ordered "Future Medical," it is now being denied by the very people who are supposed to be providing for medical treatment? What if this were you or a loved one? The next step in the process is to request what is known as an Independent Medical Review (IMR) and must be done within 30 days of the original utilization review denial.
A NIOSH Science Blog dated August 8, 2019 stated that, "Injured workers often receive powerful prescription pain medication, including opioids. In one study, 42% of workers with back injuries were prescribed opioids within a year after injury.[7] Approximately 16% of those prescribed opioids continued taking them for four quarters, with doses increasing substantially over time." It also stated, "Among women, lost‐time injuries were associated with a near tripling in the risk of drug‐related deaths and a 92% increase in the risk of deaths from suicide. For men, a lost‐time injury was associated with a 72% increased risk of suicide and a 29% increase in the risk of drug‐related death, although the increase in drug‐related death was not statistically significant. |
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Have you caught on to what's really happening here? Again, regular "Joes" cannot navigate the system alone. Joe now must burden his family financially by hiring an attorney who will represent him. But it gets better: Almost all attorneys who specialize in Workers Compensation claims work on contingency knowing very well that all cases that go before the court are worth something!
Joe's case has already been settled ... now what?
Obviously, Joe is not alone. He continues to be one of the 4.9 million workers who suffers from a work related injury. Unfortunately, the long term effects of his injury far outweigh the initial monetary settlement deemed appropriate by the court. His risk of opioid related problems increases with each and every passing day. It's been over 20 years since the original injury, subsequent surgery and court ordered settlement and now Joe needs help once again.
Pain doesn't stop while waiting for approval to be treated!
As of this date, Joe continues his daily regiment of addictive medications, getting as much exercise as he can withstand, sleep when he can, and doing things that might appear to be normal but are undermined by 8/10 levels of pain masked by the drugs. Lastly, he can now no longer hold any full time job do to lack of sleep, chronic pain, and taking the opioids.
Should Joe Be Allowed To Open His Case Back Up and Seek Additional Compensation for his Injury?
Yes
No
Should Joe Seek a Buyout from Workers Compensation and Use His Own Insurance Regardless of the Court Order?
Yes
No
This is just one of hundreds of thousands of cases in the United States that go through this same process day after day, year over year. Joe's saga is not special by any means. He is simply a victim of an antiquated and broken system of hoops and ladders.
As for Joe ... he's seeking additional care from doctors who specialize in pain management, mental health, and orthopedics just to live his new normal. If he decides to attempt to get a buy out from his "future medical" award; he'll have to seek enough compensation to cover another potential fusion in the future, on-going pain management, attorney fees, and assistance getting clean from the opioids.
Is getting into the Workers Comp System worth it ? From Joe's saga ... No!
Is your work related injury worth compensation if the company is found to be negligent? Yes.
Are frivolous lawsuits still clogging the justice system? Absolutely.
If you are injured on the job, seek advice from a trained professional and think about Joe's saga. He is not alone and you certainly don't want to be one of the statistics following in his footsteps.
Joe's WC provider: ESIS
Until next time, use your voice! The moon is the moon and the sun is the sun. If anyone tries to tell you anything different, use your voice and speak up!
References
[4] Asfaw A, Souza K. Incidence and cost of depression after occupational injury. J Occup Environ Med. 2012;54(9):1086‐1091.
[5] Kim J. Depression as a psychosocial consequence of occupational injury in the US working population: findings from the medical expenditure panel survey. BMC Public Health. 2013;13(1):303.
[6] Dersh J, Mayer T, Theodore BR, Polatin P, Gatchel RJ. Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders? Spine. 2007;32(9):1045‐1051.
[7] Franklin GM, Rahman EA, Turner JA, Daniell WE, Fulton‐Kehoe D. Opioid use for chronic low back pain: a prospective, population‐based study among injured workers in Washington state, 2002‐2005. Clin J Pain. 2009;25(9):743‐751.