Best practices for the medical management of high-risk workers’ comp and auto no-fault claims

Individuals with severe injuries often feel overwhelmed. Pain, limited mobility, financial strain, and fear about the future can compound into hopelessness. Negative emotions such as anger or depression can worsen physical symptoms, especially pain. Additional stressors such as delays in claims handling, even when relatively minor, can intensify feelings of uncertainty and worry.

For these reasons, it’s vitally important to take an integrated approach when managing high-risk claims. While the primary focus is to treat the injuries, the patient’s comorbid conditions and emotional well-being will play into their recovery prospects. The transition from care facility to home is also important. The injured person must be transitioned home safely, have ready access to needed equipment and services, and caregivers should have the training needed to support recovery goals. The following sections outline some of the most important priorities in effectively managing the medical aspects of high-risk claims.

Discharge planning is a sensitive and critical stage. Poorly coordinated discharges from the hospital or care facility dramatically increase the risk of additional medical complications and hospital readmissions. Best practices include:

• Discussing discharge needs early, and being sensitive to the emotions of the patient and their family
• Avoiding Friday, weekend, or holiday discharges
• Confirming safe transportation arrangements
• Planning ongoing transportation for medical follow-up visits
• Having translation services available when needed

Pre-existing conditions such as diabetes, asthma, and heart disease often complicate recovery. For example, uncontrolled diabetes may slow wound healing; asthma may limit rehabilitation exercises. Pre-existing conditions should be actively managed along with the primary injury.

Medication safety is one of the most difficult aspects of managing high-risk cases. During hospitalization and rehabilitation, medication regimens often change significantly from those in place prior to the admission. Without careful medication reconciliation, patients may continue to take discontinued medications alongside new ones, leading to dangerous drug interactions, duplications in medication therapy, or overdoses.

Best practices include:

• Confirming an accurate medication list at both admission and discharge from the hospital or care facility
• Ensuring prescriptions can be filled and ready for the patient before their discharge
• Training caregivers for any complex care needs, especially for injections or feeding tubes
• Performing a medication reconciliation upon return to the home to validate medication accuracy
• Securing controlled substances with lock boxes and frequent inventories

Selecting, delivering, and training patients to use DME is another cornerstone of safe medical management. The right equipment — wheelchairs, lifts, or prosthetic devices — can maximize a patient’s level of independence.  For example, appropriate wheelchair selection requires assessing the patient’s long-term needs, their upper body strength, and their ability to provide pressure relief to help prevent skin breakdown.

Key considerations:

• Obtaining occupational or physical therapist input, ideally through a home safety evaluation
• Ensuring medical devices are properly fitted and equipment is appropriate for the patient and the home
• Choosing between temporary rentals and permanent purchases of DME
• Scheduling DME delivery and providing training on its use before discharge

The shortage of home health providers makes early planning critical. Also keep in mind that home care teams are now managing increasingly complex conditions that require advanced training and careful coordination.

To be proactive, the claims professional should:

• Arrange home health services well in advance of hospital or care facility discharge
• Confirm staff qualifications and scope of practice through a qualified agency
• Develop contingency plans for staffing challenges to reduce the risk of potential hospital readmissions or medical complications

Amputation cases demand attention beyond prosthetic fitting. Unhealed wounds, phantom limb pain, and PTSD are common. Functionality depends on pre-injury activity, comorbidities, cognition, and weight. Because prosthetic devices involve large financial investments, second opinions from independent prosthetists can confirm treatment plans and prevent coding irregularities.

To support the patient once they return home, modifications are often needed — ramps, accessible bathrooms, or vehicle adaptations. Claims professionals should distinguish between essential modifications and non-essential upgrades. And because modification projects can take months, occupational therapy evaluations and contractor estimates should begin early.

Behind every catastrophic claim is a person facing one of the hardest times in their life. While clinical and technical support is vital in helping the patient recover, compassion transforms the process. I have personally seen the difference for patients when their needs are considered proactively and addressed efficiently. When this happens, the patient and their family are free to focus solely on the patient recovering.

I cannot emphasize enough the profound impact of compassionate claims management. By anticipating barriers and ensuring that patients receive what they need when they need it, claims professionals foster hope, resilience, and better outcomes.

Medical management for high-risk claims demands coordination across the healthcare spectrum, including medications, comorbidities, DME, home health, prosthetic devices, discharge planning, and home modifications. And ultimately, it’s the compassionate and proactive engagement from claims professionals that plays a vital role in establishing the course of recovery for the injured persons we serve.