Occupational Medicine—A Difficult Adjuster Call – Q2 2023

A patient presents to your center with his employer’s authorization to treat a workplace injury.

According to the patient, two days ago, he was involved in an MVA while performing deliveries, a normal part of his job. He reported the injury to his employer that day, complaining of left arm pain only. The employer called the workers’ compensation carrier, who accepted the case as a work-related injury.

On examination, the patient complained of pain in the left arm, right shoulder, and back. His physical examination shows an abrasion of his left arm, tenderness, and decreased range of motion of his right shoulder and lumbar spine.

As you are documenting his injury, you get a call from the workers’ compensation insurance adjuster. The adjuster states that the insurance company is authorizing the left arm only for treatment. In addition, the adjuster has asked you to perform a drug test on the patient.

Background

What is the role of the Adjuster in Workers’ Compensation Claims?

All insurance companies have adjusters that evaluate claims. Adjusters in workers’ compensation obtain special training and certification as they play an important part in the outcome of cases.

The workers’ compensation adjuster’s role begins when the employer reports that a worker has been injured. The WC insurance adjuster will then:

• Determine if the injury or illness will be accepted as a workers’ compensation claim. This decision is made by analyzing the mechanism of injury and OSHA and state workers’ compensation statutes.
• Investigate causation: Review the medical provider records to ensure that the medical cause of the injury or illness is related to employee’s work activities. The adjuster may ask for a causation-specific examination.
• Approve each body part that will be accepted as part of the workers’ compensation claim.
• Evaluate requests for services, such as MRI or specialty referral. The adjuster may approve the services immediately or send them to medical peer review for evaluation. Sometimes, as in this case, they even suggest tests.
• Approve payments of employee benefits.

After the adjuster’s phone call, what should you do next?

Naturally, patient care always comes first. Regardless of the adjuster’s instructions, fully evaluate the patient, and take X-rays as you would in any other case. If additional testing outside the capabilities of your center is required immediately, send them to the ED without hesitation.

After your evaluation, if you believe the associated symptoms, in addition to the left arm, are related to the accident, document this fact clearly and unambiguously in the chart. A statement such as, “After review of the mechanism of injury and examination of the patient, I have determined that the right shoulder and back are related to the injury that occurred on 1/2/23.” It may sometimes be necessary to talk to the adjuster who may initiate a call, depending on the circumstances of the case.

What about the adjuster’s request that you perform a drug test?

Do not perform a drug test based solely on the request from an adjuster or patient’s employer. You must complete an independent evaluation of the patient. If the patient shows signs of intoxication, you should document them and do a drug test only if it is justified.

In future articles, we will discuss the roles of some of the other stakeholders in the complex world of workers’ compensation.

You can reach Dr. Lebow at:

Max Lebow, MD, MPH, FACEP, FACOEM

Medical Director | Board Certified in Occupational Medicine and Emergency Medicine

Reliant Immediate Care Medical Group, Inc.

Insight Practice Partners RCM, Inc. 

(o) 310.215.6020

mlebow@reliantuc.com | www.ReliantMedicalCenter.com