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This article is aimed at discovering the role a good workers’ compensation claim adjuster has surrounding opioid use as a treatment for an injured worker.


It seems that everyone from the President of the United States to state governors and legislators has come to the realization that the opioid epidemic in our country is out of control.  Whether it be a crackdown on pharmaceutical manufacturers or medical providers, the story is at the forefront of the nation.

At the front of this battle are claim adjusters who work directly with injured workers, employers, and medical providers; who work diligently and in good faith to rehabilitate our country’s injured laborers.  When we think about a crisis with this level of attention, we may not first think about the role of the workers’ compensation claim adjuster as much as the role a doctor or treating facility has with properly treating the injured worker.

As a workers’ compensation third party administrator, you want to have good claim adjusters whose experience and wisdom makes a major difference in this battle; you want good claim adjusters who recognize the value of a productive employee in the workforce.  The key word is “productive.”

In workers’ comp, we think of “productive” as someone who returns to work in a full capacity position or into a light-duty job if possible.  A return-to-work (RTW) strategy is part of the rehabilitation process just as proper medical advice and prescription treatment are to an injured worker's physical recovery.  It is this combined effort that makes the claim adjuster’s role in the opioid epidemic that much more important.

Recognizing The Value of a Productive Employee 

A good claim adjuster first makes certain the injured worker receives treatment from a reputable provider.  A good claim adjuster establishes a positive rapport with the medical provider alerting the provider to the worker’s injury and employment.  In select jurisdictions, the claim adjuster has the ability to offer a selection of providers to choose from upon initial visit.  Conversely, in select jurisdictions, the claim adjuster has the ability to change providers upon his or her own professional recommendation to the injured worker as well as upon request of the injured worker at any time during treatment.

A good claim adjuster encourages the injured worker to be productive while taking necessary opioids.  A good claim adjuster maintains contact with the injured worker after initial contact to develop a good rapport, putting the injured worker’s best interest in mind first and foremost. 

A good claim adjuster works with the employer for RTW and motivates the injured worker to balance work with improvement.  An example is making sure the injured worker is taking opioids as needed at night or only at home.  This condition may be based on the employer’s requirement not to be on pain medications during work hours or on the commute to and from work for safety reasons (liability).

A good claim adjuster listens to the injured worker to determine if the opioids are helpful or harmful to their overall improvement.  In select jurisdictions, the claim adjuster may even assign a nurse to assure the injured worker that he or she is receiving the proper care from the medical provider.

In situations where the claim adjuster may doubt proper opioid use by the injured worker, a good claim adjuster may work alongside a medical provider who orders routine or sometimes random drug screening.  The purpose of the screening is to be certain the opioids are being used properly for the injured worker’s benefit and as prescribed.  For example, a urine analysis review by a good claim adjuster can be effective as follows:

  • It can detect if proper levels of prescribed opioids are in the injured worker's body
  • It provides a safety mechanism by which to determine if meds are being mixed
  • It detects whether meds are simply being taken at all for the injured worker’s treatment benefit 

Experience Makes A Difference

Knowing injury types and severity plus pain meds make a good claim adjuster better prepared for knowing what pain med treatment is or isn’t needed.  The wisdom that comes from experience along with collaborating with the right medical personnel, gives the adjuster the knowledge to identify the correct opioid/script type, the proper number of scripts prescribed, an ideal pill count for each prescription, and the dosage (mg) prescribed.

A good claim adjuster is better prepared to question the medical provider or provider practicing manager, request a peer review or independent medical exam (IME), and question if the doctor is suitable to continue treatment for the injured worker.  If necessary, the adjuster can take the final step of filing a formal complaint against a medical provider.  For example, a medical provider prescribed Oxycodone 80 MG ER #60, Oxycodone 40 MG ER #30, and Morphine SUL 15 MG #60 to an injured worker.  The injured worker recognized the power/effect of these combined opioids when taken together and immediately discussed this with his claim adjuster.  With the adjuster’s wisdom and pro-action, the injured worker's overuse and potential overdose may have led to the worker's death.

Recognizing an overprescribing doctor alerts a good claim adjuster to seek a number of resources. Resources who may be alerted include:

  • Other fellow claim adjusters who administer claims in the same territory (“please consider your choice of medical provider”)
  • Possibly the district attorney’s office or DEA through a DA (under circumstances where other good claim adjusters complain repeatedly)
  • Select PPO networks who seek reputable pain med doctors
  • The injured worker’s employer to know not to seek out that provider for future medical attention

Knowing injury types and severity better prepares the good claim adjuster to recognize any follow-up surgeries or long-term injury that may require continued use of pain medications. For example, corrective surgery that causes further pain, ongoing, long-term treatments for an old injury, and treatment for a secondary injury resulting from the initial injury.

Having good claim adjusters who are well-rounded in identifying injuries, determining injury severity, and understanding the impact that opioids can have in a positive and negative way can help a third party administrator work most effectively for any entity’s injured workers.  The good claim adjuster along with a knowledgeable and aware employer can make all the difference towards positive outcomes like return-to-work, quicker recovery, and coordinated care and concern for the injured worker.


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