Can You Identify Red Flags in the Life of a Workers' Injury?

Posted by The ALS Group on May 15, 2013 12:51:26 PM

Certain indicators early in the life of a workers’ injury are red flags — a strong possibility your employee’s healing will be delayed or that the claim may be fraudulent. If you notice any of the following signs, discuss the claim with your adjuster as soon as possible. Once the management of a workers’ compensation injury goes astray, it is usually difficult to bring it back to center.

  • Watch those opioids. One expert predicted that the insurance industry would spend over $1.4 billion on narcotics for workers’ compensation injuries in 2012 while the “vast majority” of the prescriptions are unnecessary (see WC 2012 Issues Report). Injuries that require narcotic prescriptions such as OxyContin® and Percocet® should be the exception. While we hesitate to second guess doctors, if you question the need for narcotics, call your adjuster and request they discuss the prescription with that physician. Prescriptions for narcotics increase the likelihood of longer terms of work disability, according to the National Council on Compensation Insurance (NCCI) and other studies. For example, NCCI found that laceration injuries with opioid use have 50-to-100 percent longer temporary total disability durations than laceration injuries without the use of opioids. Sprains, contusion and inflammation injuries show a 50 percent longer disability period, as well.
  • Late reports of injury should trigger a full compensability investigation. Be sure your employees understand that they must report all suspected injuries on the date of the incident, whether or not they go to the doctor.
  • Investigate unwitnessed injuries. Immediately check for video surveillance to see if the video confirms the details of the first report of injury. Even if your employee is  injured off-site, many locations now have video surveillance.
  • While your injured worker may be on disability, he or she may be engaging in activities outside the restrictions imposed by the doctor. Coworkers often have information about an injured worker’s activities.
  • Carefully investigate any injuries that occur in the first few months of hire. Talk with witnesses, supervisors and coworkers. Review employees’ social media site entries after a workers’ compensation claim. These entries can help determine if employees on disability are acting outside their alleged physical limitations. Social media is increasingly becoming a very useful tool in injury claims investigations.
  • Injuries filed after a change in employment status, such as layoffs, terminations or demotions, require special scrutiny. It is very hard to dispute these claims, but a full compensability investigation after an employment change may show that the claim is based on a grievance, not fact.

The first goal after stabilizing an injured employee’s medical condition should be to get that employee back to work. The red flags listed above may delay an employee’s healing and return to work, which will increase your claims costs and degrade your experience modification factor.

By engaging the services of an independent advisor who can mature/develop and track you claim handling process, you can use a team approach on each injury and help to return your employees to productivity and full physical function.  Doing this can greatly reduce your organization’s Total Cost of Risk (TCoR) and give your bottom line a boost.

If you have questions or need help with your current claims handling process, please feel free to contact me at 732.395.4251 or


Topics: Claims Handling, Claims Management, Claims Management Process, HCP, Human Capital, Human Capital Practice, Risk Management Blog, TCoR, Total Cost of Risk (TCoR), Worker's Compensation

The ALS Group

Risk Management Blog

We manage more than a quarter billion dollars of premiums for a diverse range of clients around the globe. 

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