Case Management Atrocities

By Phil La Duke

Nobody likes a cheat.  Whether the cheater is fraudulently collecting disability insurance that is not his or her due, or the cheater who fakes an injury so that she can get undeserved light duty.  But I have noticed an alarming and disappointing tendency among organizations who brag about their case management as if, cheating injured workers out of their legal claims of disability pay.

Before any of you furrow your brows and type of an indignant “how dare you…” email, I am not talking about those among us who act in good faith and try to weed out the dishonest who steal from the company by claiming injuries that don’t exist, or that exist but were caused outside the workplace.  But on the other hand, if this hits close to home, maybe you ought examine your conscious and if it sounds like I’m talking to you I probably am, and if I am, you should be ashamed of yourself.

Let’s begin by level setting. No one wants to get hurt, and while there are some people with larcenous hearts, most people (and I use the word “most” judiciously and correctly—to denote the majority of people, as in more than half.) don’t want to take money fraudulently.

Most Claims Are Legit

I further believe that most injury claims are legitimate; people get hurt, report, the injury and hope to get back to work as soon as possible.  I believe that most fraudulent claims are at least on some level legitimate; people get hurt but they either exaggerate the extent of the injury or deliberately milk the time off work so they can malinger while living on the dole. But there’s a lot of grey area between the legitimately injured and the fraudulently injured, and too often organizations treat all injured workers as if they are liars and thieves.

Misguided Case Management Workers

There are some case management professionals who view the core purpose of their jobs as denying benefits.  Most are decent, ethical people, but they may still be under the mistaken impression that denying disability benefits on a technicality is the right thing to do. This may not be their fault.  A friend of mine has been a policeman for over twenty years. He told me that if he had it to do over again he would have chosen another career.  Not because he doesn’t have the same values that led him to chose that path in the first place, but because, as he explained , a policeman tends to see people when they are at their worst (watch an episode of Cops and you will understand what he’s talking about). So I guess I shouldn’t blame a veteran case management professional who starts to view injured worker with something of a jaded eye, but this assumption that workers are guilty until proven innocent hinders our ability to create a culture where workers value safety.

While some people do fraudulently make claims (after all, if they didn’t, it’s likely that claims management wouldn’t exist, or at least it wouldn’t exist to the extent that it currently does) it’s the grey areas that case management can get dicey and where otherwise compassionate and ethical case managers are tempted to go off the rails, morally speaking.

Take for example, the case of worker who strains his back on a Friday but doesn’t report the injury and then helps his brother-in-law roof his house.  In the middle of roofing job, he realizes that he has been injured more seriously than he initially believed.  He reports the injury on Monday. In this case, the claims management team is likely to dispute the claim (because a weekend has passed between the alleged injury and the claim.) If the worker is honest and admits that he had been engaged in manual labor on the weekend the claim is likely to be denied, even though it is completely legitimate.  In this case the case management professional has to little choice but to dispute the claim.  The tragedy here is that the fraudulent claimant is far more likely to seek the services of a skivvy lawyer that specializes in fraudulent medical cases while the legitimately injured worker is punished for telling the truth.

What’s more, this is a situation that most organizations have created.  They offer incentives for not reporting injuries—safety BINGOs, bonuses for no injuries, and similar programs make it uncomfortable to report an injury, even one that the injured party knows is a legitimate workplace injury.  The dirty little secret of too many behavior based safety programs is that they encourage injured workers to seek outside medical attention and keep the injuries off the books.  While this is a great way to make the company’s safety record look good, it’s basically just juking the stats.

The Nuremburg Defense

I am sure to get a view angry emails that defend Case Management abuses (and they are abuses even if they are the by-product of unintended and subconscious biases) as attacking case management professionals for “only doing their jobs”.  I reject this criticism out of hand.  No one can every justify doing the wrong thing by claiming that he or she is only doing his or her job.  It didn’t work for the Nazis and Nuremburg and it doesn’t work for case management workers.  The key to ethical case management is in training and in expectations.  Those who provide medical attention to workers need to understand that the difference between a recordable injury and one that is not is often as simple as the kind of pain reliever administered to the worker.  This is not to say that a physician should be discouraged from doing what’s best for the patient, but all things being equal why not avoid a recordable?

Workers should be trained on the importance of timely and accurate reporting of injuries and more attention should be focused on eliminating injuries, identifying and reporting hazards and near misses, and drawn away from denying claims.

Further, claims managers should be taught that their jobs aren’t about catching cheaters, rather, it is to protect the workers from being wrongly denied benefits at the hands of corporate jackals, and protect the company from people who would rather sit home watching Judge Judy and fraudulently collect disability funds. It’s a undeniably a tough job, but one they chose, after all, it’s not like they were pressed into service after getting falling down drunk in a waterfront pub.


#claims-management, #fraudulent-injury-claims