The word “catastrophic” congers up images of motor vehicle accidents, falls from great heights, building collapse with resulting injuries such as spinal cord injuries, severe burns, amputations, loss of eyesight or neurological injuries. While these are common types of catastrophic injuries, any injury requiring extensive medical treatment and/or has a lasting impact on one’s life is classified as a catastrophic injury.
Thankfully, catastrophic injuries make up only a small fraction of the total number of workers’ compensation claims. However, the significant medical care required by these type cases accounts for a heavy financial burden. The proper management of these high dollar claims makes a significant difference in the cost of the workers’ compensation program.

As soon as the work comp adjuster receives a case that involved a major injury or hospitalization, it is imperative for the adjuster to act immediately. The adjuster needs to drop everything and concentrate on the catastrophic injury claim. The first recommendation is to contact all parties involved (worker, family members, supervisor, witnesses, Human Resources, hospital, physician, etc.) and also assign a nurse case manager.  The goal is to obtain as much information as possible in order to get a comprehensive understanding of what occurred.  Time is of the essence and it is important to obtain the information while it is fresh on everyone’s mind.

The case manager should also make arrangements to personally meet with the employee and/or his/her family member(s) at the hospital, preferably same day the injury occurred. Contact by the adjuster and the nurse case manager the same day as the accident is reported is critical to the outcome of the claim.
The injured workers’ primary concern is simply to survive the injury. The second thought is, “What do I do now?  How will this affect me and my family?  Will I be able to return to work?”

Most injured workers are contacted by a local attorney who has staff that regularly scours public records for new cases. If the injured worker is confident that he/she will receive the appropriate medical care, and that indemnity benefits will be paid, the probability of the employee hiring legal representation is greatly diminished.  In many cases attorney representation increases the employee’s recovery time and also increases medical costs secondary to defensive medicine practiced by the physicians involved.   Establishing rapport with the employee and/or family members is imperative.

Medical Management:

The intensive involvement of the work comp adjuster in the initial stages of the catastrophic injury claim is of paramount importance. Early medical management is essential to achieve the best possible medical outcome. The highly trained nurse case manager should handle the day to day medical management of the claim.

The nurse case manager is responsible for insuring the employee receives proper medical care throughout the life of the claim. This continuity of the medical care is critical to the best possible outcome for the employee. It also prevents the medical care from drifting to non-covered issues and prevents the claim from growing larger than necessary.

The nurse case manager works with the employee to guide the injured worker through the significant life changes that follow a catastrophic injury and help make sense of the treatment recommendations. As the employee goes through hospitalization, rehabilitation, and a return to home and community activities, the nurse case manager recommends the necessary work accommodations and treatment needed to succeed with a return to the work environment.

Along the way to recovery, or maximum medical improvement, the nurse case manager will continue to work with the treating physicians, specialists, therapists, rehabilitation providers, if the employee is unable to return to work. For those employees who are permanent and totally disabled and not able to return to work, the continuing involvement of the nurse case manager is necessary. The expertise of the nurse case manager in managing the medical aspects of disability and in determining the appropriate home-based care will impact the overall cost of the catastrophic work comp claim.

In summary, catastrophic claims which are not appropriately managed by the adjuster and assigned to a nurse case manager can quickly spiral out of control thereby drastically increasing the overall cost of the claim.  Immediate attention to the medical needs, establishing rapport and controlling costs of the medical care, has a positive impact on the overall cost of the workers compensation claim.