April 1, 2020 • Education

Mental Health Services Before & After Settlement

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Historically workers’ compensation insurers and employers avoided “psych” claims for fear that services would never end, and costs would spiral out of control. During the past decade however, the industry has come to recognize that mental health issues can increase claim duration and costs, and have developed focused programs to help injured workers cope. Additionally, recent changes in billing codes now allow assessment and interventions for so-called psychosocial issues vs. psychiatric claims. Helping injured parties address mental health and substance abuse issues before and after they settle claims has become a game changer.


Attention to mental health issues coincided with the opioid crisis and the subsequent need for addiction and dependency treatment. The industry has implemented effective programs to eliminate or reduce initial use of opioids, and explored alternative pain management programs. However, many older claims still are prescribed dangerously high doses of opioids. By the time injured workers settle their cases, many have used opioids for years and struggle with dependency or addiction and risk overdose. The National Alliance of Medicare Set-Aside Professionals (NAMSAP) estimates that 70 percent of the Medicare Set-Asides (MSA)s approved by the Centers for Medicare and Medicaid Services (CMS) allocate funds for opioids. Keep in mind that if opioids are prescribed within six to 12 months prior to MSA submission and settlement, CMS allocates funds for those amounts and dosages over the injured worker’s expected lifetime.  For years, NAMSAP has lobbied CMS to change this policy, arguing that funding a lifetime of opioids essentially “encourages, intensifies and effectively orders long-term opioid use and abuse by Medicare beneficiaries.” Taking a step in the right direction, CMS updated its 2019 Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide (version 3.0) to say, “CMS highly recommends professional administration where a claimant is taking controlled substances that CMS determines are ‘frequently abused drugs’ according to its Part D Drug Utilization Review (DUR) policy.”  Professional administrators whose members use their discounted pharmacy network can monitor Morphine Equivalent Doses (MEDs) and possibly intervene when the levels exceed clinical guidelines. Utilizing the Part D drug utilization review process would provide administrators an authoritative body to back the preventative measures they are implementing.  Incorporating these opioid management protocols would enable professional administrators to track more aggressively MEDs, alert members to the risks of chronic opioid use, and notify providers to help prevent overdoses. Without that authority, members could view administrator interventions as overstepping their  role.


States are slowly beginning to address another mental health issue, post-traumatic stress disorder (PTSD).  Programs mostly apply to military, first responders and law enforcement.  Many state-based organizations are lobbying for workers in these categories to receive presumptive PTSD coverage. PTSD can be successfully treated, but only when addressed early in the diagnosis.


Depression combined with drug abuse is more common among injured workers than many may realize. A recent study published in the American Journal of Industrial Medicine showed a nearly “3-fold increase in combined drug-related suicide mortality hazard among women,” and “a substantial increase among men,” for injuries that incur more than a week of lost time. A separate study from the same publication added to a growing body of evidence suggesting “the status of disability itself as the primary cause of both an overall decline in health and an increased risk of death from opioid overdose.” The BMC Public Health-published “Depression as a Psychosocial Consequence of Occupational Injury In The US Working Population: Findings From The Medical Expenditure Panel Survey” determined that workers with occupational injuries were more likely to experience depression than those whose injuries were not work related.  Separate research published in the Journal of Occupational Rehabilitation, found that workers with lost-time musculoskeletal injuries, demonstrated depressive symptoms within the first year after the injury. Depression was also associated with poor return-to-work outcomes. The loss of professional identity, routine, and social interactions associated with the workplace were found to contribute to depression. There can also be a loss of status among friends and family. Additionally, the inability to return to work usually means the person’s standard of living is reduced, causing anxiety about the future. Obviously, helping injured employees return to their original positions or secure new jobs is important. Some injured parties may be stuck in a disability mindset due to psychosocial issues. Catastrophizing, perceived injustice, and fear avoidance are examples of psychosocial factors that can render an injured worker nearly paralyzed. Screening for these early in the claim can facilitate return to work.  Interventions such as short-term cognitive behavioral therapy have been proven highly effective for many of these injured parties and can be implemented without accepting a claims as psychiatric in nature. In the early 2000s, new medical billing codes were added for health and behavior assessment and intervention, instead of psychiatric evaluation and treatment. Claims that do fall into the psych category may or may not be compensable. Jurisdictions vary in terms of how they treat mental health in workers’ compensation. In general, one of the three following criteria must be met:
  1. Physical/Mental. Mental illness due to a physical injury, e.g., a person becomes clinically depressed because of a work-related physical injury or illness.
  2. Mental/Physical. Physical injury due to mental illness, i.e., the stress of the job causes ulcers.
  3. Mental/Mental. Non-physical mental injury, job stress leads to a mental breakdown. Coverage for this tends to be occupation specific, and many states’ language specifies that the occupational stress must be extraordinary and unusual, compared to that experienced by the “average” employee. Statutes do not define “average.”
In addition, a board-certified psychiatrist or clinical psychologist needs to determine that there is a true mental health diagnosis, and that the symptoms are related to a work-related illness or injury. Successful return-to-work programs feature early and strong communication to help the employee stay connected to work. Focusing on ability and function rather than disability, diagnosis, and symptoms plays a role in setting expectations. Modified job duties, supportive supervisors and co-workers, workplace ergonomics, involved treating physicians, and behavioral counseling are important factors to set the stage for returning to the workplace.


Unfortunately, many catastrophically injured employees are permanently unable to return to any type of employment.  Some cannot perform basic life activities, like bathing, lifting, eating, and ambulating or using devices to move without supervision or assistance...Plus, many suffer from chronic pain, which can add to feelings of hopelessness. Ensuring that these people receive the behavioral support they need is critical. When these seriously injured employees settle their workers’ compensation claims, their medical problems - including mental health conditions, don’t disappear.  In fact, those who remain unemployed are at a high risk for depression and anxiety. Fortunately, paying for mental health care after settlement can be easier than securing coverage for it during the active treatment phase of the workers’ compensation claim. MSAs will allocate these costs when appropriate.  Ensuring that these injured workers receive the care they need post-settlement is another reason to use a professional administrator. Administrators offer 24/7 care advocate support to help identify physicians, physical therapists, durable medical equipment vendors and a wide range of psychologists, psychiatrists, and licensed social workers. A professional administrator can help identify alternatives if the injured person needs a new treatment provider. Some administrators also develop extensive medical networks and provide pharmacy discounts to help stretch medical settlement dollars.  If payment for services is an issue, care advocates can often help them find community-based services and other methods to receive a full range of mental health services. Care advocates can answer questions and provide support.  Keep in mind that post-settlement, the injured worker no longer has the adjuster or case manager to lean on.  While customer service representatives are not typically clinicians, representatives can be trained by clinicians to help injured workers who are dealing with mental health issues by using techniques such as:
  • Utilizing active listening skills so the injured worker feels a connection
  • Using words and phrases that indicate a person is dealing with mental health concerns
  • Asking appropriate questions to help draw out problems
  • Identifying ways to keep the injured worker on the phone and seeking help
  • Providing education and other resources
Some injured employees lack supportive families and are living alone by the time they settle their claims.  Isolation and loneliness are prevalent and having a friendly person to talk to can be a life saver.  Literally. A recent incident involved a member telling his care advocate that he was considering suicide and that he had a gun in the house.  The advocate kept him on the phone and conferenced in a suicide help line and held a 3-way call until authorities arrived to help him.  Since then, the injured party has sent several notes thanking the team for saving his life.  As a result a partnership was developed with a professional crisis management organization to assist with these instances. While a negative stigma surrounding mental health issues persists, it has lessened somewhat.  Injured parties are becoming more willing to accept help.  However, challenges remain when seeking care.  Many behavioral health counselors do not accept workers’ compensation.  Only about 55 percent of psychiatrists accept any insurance assignment and other behavioral health professionals also tend not to accept insurance or Medicare. Post-settlement, payment becomes a little easier.  Fees for mental health care can be allocated into an MSA under certain circumstances, thus creating a cash-payment situation that therapists prefer. Yet the individual may not be able to continue treating once they appropriately exhaust their MSA, as many providers refuse tobill Medicare. Additionally, some post-settlement injured workers do not want to leave home to see a therapist.  Transportation and just getting out of the house are difficult for some, and others just resist. The growing acceptance of telehealth and an abundance of new technologies may help overcome that barrier. According to a Fair Health whitepaper, 31 percent of claims studied involved telehealth for mental health care.  A plethora of mental health therapy apps have emerged; there are roughly 10,000 available. Some suggest daily activities to boost mood and to identify and change negative thoughts.  Others connect people with live, licensed therapists who connect over text, voice or video messaging. Mental health care in workers’ compensation has come a long way. Strengthening the industry’s understanding of mental health conditions and their treatments, while embracing supportive technologies, will lead to better care and outcomes. Read the full article in IAIABC's March Perspectives Issue.

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