Reviews of psych claims in comp increase

Requests for independent medical examinations for workers compensation claims with a psychological condition are rising, in part due to greater awareness of post-traumatic stress disorder and an increase in workers seeking treatment for depression and anxiety in conjunction with a physical injury, experts say.

While exact numbers are hard to pin down and the increases vary by state, psych IMEs often are more costly that physical exams are driving comp costs higher, they say.

“There is not a lot of data on PTSD, but we are seeing it on the rise,” said Donna Bradshaw, Philadelphia-based vice president of independent medical evaluation services for Genex Services LLC, which manages comp claims for employers nationwide.

Over the past two years, Genex has seen a 20% uptick each year in referrals for secondary, independent evaluations for psych conditions attached to workers comp claims, according to Ms. Bradshaw.

The volume of psych evaluations and the circumstances in which they are paid via workers comp varies by state. Data compiled by the Cambridge, Massachusetts-based Workers Compensation Research Institute shows that all but 16 states accept workers comp mental injury claims where no physical ailment is present.

Some states have limitations on psych claims. For example, Florida only allows for a post-traumatic stress disorder, mental-only claim if a worker is a first responder; Minnesota only allows mental claims involving post-traumatic stress disorder and does not allow ailments such as depression and anxiety alone to be covered by comp.

Each state has rules on accepting mental claims and establishes when an independent medical evaluation or review can come in following an initial diagnosis, according to WCRI’s report on workers comp laws published earlier this year.

Nationwide, psych-related evaluations are the second most commonly requested IME at Genex, Ms. Bradshaw said.

Mental injury claims, either attached to a physical comp claim or standalone, are increasingly becoming an issue in contested comp claims, said Amy Bilton, a shareholder at the Chicago office of Nyhan, Bambrick, Kinzie & Lowry P.C., who represents employers in serious comp claims, often stemming from debilitating injuries or acts of violence.

PTSD is increasingly a common condition in claims but often it’s added later, which employers say can be attempts to prolong the claim, an industry term known as “malingering,” she said.

“People are getting a whole lot more treatment than they used to and in my practice in Illinois a lot of the cases I see start off as legitimate and then turn into malingering, which is why IMEs are being requested as frequently as they are,” said Ms. Bilton.

A psych IME often involves days of examinations and can expand to interviews with relatives of an injured worker, Ms. Bradshaw said. “It’s more intensive than a musculoskeletal” IME, and more costly, she said.

Data on IMEs in workers comp is limited, but trends in California — which is often a bellwether state for comp developments — could be telling, experts say. The Oakland-based California Workers Compensation Institute in April 2019 released its annual data on independent medical review decisions, showing that requests for psych services between 2015 and 2018 made up less than 1.4% of IMR requests, a sign that such claims are not disputed. But fewer of them are being overturned on the secondary medical evaluation.

CWCI data shows that 78.8% of IMR decisions in 2018 upheld earlier treatment decisions, the second-lowest uphold rate after “evaluation/management” decisions and a 5.6 percentage-point drop from the 2017 figure that showed 84.4% of treatment decisions upheld for psych services. By comparison, in 2018, 89.3% of treatment decisions regarding pharmaceuticals and 91.3% of decisions in physical therapy were upheld.

California’s surge into mental-injury acceptance became a problem in the 1990s and was addressed by state reforms since, but is still prevalent, according to Jeff Adelson, a partner with the Newport Beach, California, firm Adelson McLean P.C., which represents employers.

“There was a time it became almost commonplace in every case,” said Mr. Adelson.

“It became more difficult to prove” with reforms “but it did not go away,” said Mr. Adelson, adding that cumulative trauma claims that mostly deal with musculoskeletal injuries are increasingly seeing a psych component added.

“If someone has a severe injury that is interfering with their daily life, it is not surprising to see (a psych component),” he said. “It has become very costly; we are not talking about where someone suffered some serious psych injury, we are seeing it in cumulative trauma claims; we are seeing attorneys advertise on television; some of the medical records and depositions we look at, they ask (the injured worker,) ‘You don’t feel good? You are sad, aren’t you?’”

“There are incidents in people’s life that causes sadness; we are seeing a lot of those,” he said. “What’s really becoming difficult is that years ago these qualified medical evaluation reports might be 23 to 30 pages; now we are seeing situations where these reports are running up to 100 pages or more.”

“I think it is coming to other states and I think that is where the concern is,” Mr. Adelson added.

Ms. Bilton said another element in investigating comp claims is also increasingly making its way into the psych arena: surveillance.

She told of one recent incident in which a man was attacked at work, a claim that had been verified, but that he went on later to add a PTSD component to his claim, saying he could not leave the house out of fear and thus could not work.

Surveillance footage captured the same week of his independent evaluation showed him working as a nightclub bouncer, breaking up a fight between patrons, she said. “When he came in (for his evaluation) he had bruises on his face from breaking up a fight and he is saying he is afraid to go to work because of an attack,” she said. “In my experience, this is a way to stay out of work for some claimants.”

This article was first published by Business Insurance.

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