What Are Legacy Claims and How Can These Be Settled?

by | Published on May 20, 2019 | Medical Review Services

Legacy claims or old claims contribute to higher costs for employers and insurers and work to bring down the bottom line of an organization. Aging claims usually pertain to injured employees who take longer than normal to reach the level of maximum medical improvement or MMI, injured employees who have reached MMI but require further medical maintenance, and employees who are permanently totally disabled. The legitimacy of a workers’ compensation claim is established through a review of the claimant’s medical records for which attorneys utilize the service of a company providing medical record review for medical legal consultants. A worker who is receiving benefits is expected to return to work once he/she has reached maximum medical improvement. Legacy claims arise or claims remain open when the employee’s medical condition continues to lingeror when there is an industrial commission ruling on that particular claim. When legacy claims continue to exist, they can cause considerable financial drain especially for self-insured employers. Therefore attempts must be made to resolve such claims.

What are the main reasons for the existence of legacy claims?

  • Atypical or unusual recovery time. Claimants who have reached MMI continue taking treatment or medication that make such claims very costly.
  • Preliminary investigation into the nature and extent of injury was inadequate
  • Workers’ compensation adjusters didn’t receive proper claims training
  • Inadequate medical management throughout the period of the claim
  • Loss of continuity in claim handling because of change in adjusters
  • The adjuster attending to legacy claims may also have many other claims assigned. As a result, they may miss any opportunities that may come up to settle the claim.
  • Employees may disagree on the total value of settlement
  • Employees are concerned that their financial resources will be drained
  • Employees fear non-compliance with Medicare and other insurance regulations when they are on their own after settlement

Often, claims drag on because employees are concerned about being on their own once a claim is settled. In fact, adjusters have contacted injured workers to find out whether they would like to settle only to realize that they didn’t want to do so.

How can employers address the issue of legacy claims?

The first thing to do is have a representative who will be at the head of the claim settlement initiative. An in-depth review of each claim is essential to identify issues and points that may have been missed earlier. Red flags to look for include evidence of high opioid use, multiple prescribers, brand name medication, inconsistent medical records, obsolete medical records, and outstanding medical or surgical recommendations. Employers should decide whether to focus on cases that are very old or cases pending in a particular state. When reviewing legacy claims, it is best to consider current and future medical treatment and utilize tools such as evidence-based injury guidelines. Other considerations include the following.

  • If the employee is not currently working, recommend a return-to-work program whether with his/her own company, or vocational training to work somewhere else.
  • If the case is currently being litigated, review the litigation plan.
  • Recommendations regarding whether or not to go for an all-inclusive settlement of the claim.
  • Recommendations regarding financial offsets such as social security disability, subrogation, state disability, second/subsequent injury fund, recovery from excess carrier and so on.

Following the review, the claim can be settled if the claimant is no longer undergoing treatment or if the estimate for future medical care is reasonable and is in line with the employer’s expectation of the settlement amount. In case the estimated future medical care is beyond what the employer thinks is reasonable in terms of settlement, intervention could be considered as an option. It can be clarified with the claimant as well as the treating physician whether certain medication is still being utilized. If the claimant is on multiple medications, a physician peer reviewer can review and compare those against evidence-based guidelines to decide whether the medication regimen is appropriate for the claimant’s particular condition. Another option is to discuss alternative medications.

Claims become complex over time and it is important that they are not left unchecked. Though only a small number of claims in workers’ compensation become legacy claims, they account for a large portion of the cost associated with the overall program. That is why it is vital to understand trends and take the necessary steps to amicably settle those claims. It should be noted that as claims age, employees also age and as workers’ compensation attorneys as well as providers of medical review services that assist them know, it is highly possible that many health conditions will emerge along with increasing age and this could cloud an injury’s cause and effect. Employers should focus on reassuring their employees and alleviate any fear they may have via clear communication and by expressing empathy towards them. Employers should try to understand the claimant’s needs and concerns. This would help with claim settlement in a more amicable way.

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