 Welcome to Much More on Medicine on Think Tech Live Streaming Network series, broadcasting from our downtown studio at Pioneer Plaza in downtown Honolulu. I'm your host, Catherine Norr. Joining me in the studio is Attorney Natalie Pettit. Today we present how workers' compensation works, believe in possibilities, not disability. Remember that our talk shows are streamed live and the internet from 11 a.m. to 5 p.m. every weekday and earlier shows are streamed all night long. All our shows are streamed on livestream.com. If you want the links to our live streams or previous broadcasts, which are available on youtube.com, or if you want to just subscribe to our programs or get our mailing lists and get our program advisories, go to thinktechhawaii.com. I'm delighted to be talking with Workers' Compensation Attorney Natalie Pettit. Natalie is a former prosecutor in the U.S. Army Judge Advocate General's Court. In 2003 she served in Iraq as the legal advisor for the commander, 24th Corps support group. She came to Hawaii the following year as the chief of international and operations law with the United States Army Pacific. More than a decade, Natalie has concentrated her law practice in the field of workers' compensation. Natalie, so as a work comp attorney, what do you do? I review a lot of medical records, so workers' compensation is essentially insurance that employers are required to provide so that when they have workers that are injured on the job, their workers are taken care of. Because it involves work injuries, it's really heavily intensive on review of medical records. I spend a large part of my day reviewing those matching facts with the law, with existing cases to see how we can get injured workers the medical treatment that they need and get them back to work as quickly as possible and in the most cost-effective manner. I know as an insurance defense attorney myself that I do review a lot of medical records and I think people think that attorneys, we spend all of our time on the law, but I know that in my practice I do a lot of arguments related to medical issues. Is that what you do as well? That's exactly what I do. So we have to know the case, we have to know the records in order to make sure again that we're getting the injured worker the treatment that they need. The law requires that we provide reasonably necessary medical treatment for the work injury. As you can imagine, and I'm sure you might see this in some other cases as well, that when there is an injury to particular body parts, sometimes that injury then spreads to other body parts or other body parts become to be involved in the claim. So it's just very, very important to have a good grasp of the medical history of the person to look for any pre-existing conditions, any subsequent intervening injuries, and just to find out what's going on with the case. Okay, so what are the most popular types of injuries that people receive or the most common in work place environments? I don't think any injuries are popular, but we do see certain injuries quite frequently and those involve low back injuries for the most part, some neck, repetitive injuries such as carpal tunnel syndrome, lots of shoulder injuries, elbows, knees, that type of thing. Okay, so one thing that I've noticed in my work is there tends to be when I said popular, sometimes there are injuries that seem to be more common during particular time periods, and I've noticed that years ago it was TMJ disorder issues and now it's traumatic brain injuries. Have you ever seen a trend in the type of injuries or does that not exist in your work? We see different types of injuries across the board and that hasn't changed, but I think as more research is done we do see an increase in traumatic brain injuries in PTSD. There's been a lot of research done, as you know I was in the military, so with soldiers coming back for more, there's been just a lot more research done in that area and they're finding obviously that it pertains not just on the battlefield, but it can happen in other areas as well, including work injuries, so that I have seen an increase in those types of injuries. Now, okay, so what is workers' compensation? So workers' compensation again is insurance that an employer is required to maintain. They can either be self-insured or they can have insurance and if they're self-insured they have a third party administrator who administers any work comp claims for them. If they're insured then they just have an insurance adjuster that does that. And a lot of times I hear people complain and gripe about the insurance carriers, but the adjusters who are working on the files, they live in our community. These are our neighbors. These are the people whose children go to the same school as ours. We see them in the library. We see them in the grocery store. They're part of our small community here on Oahu and my experience with the adjusters is they really, really care about their jobs. Some of them are very busy so you'll find that when you're working with them that they do have a busy case load, but they care. Okay, and I know you're very busy and so we appreciate you taking time out of your day to be here. What exactly does work cover? So if a person is injured at work, a workers' compensation insurance will cover any medical treatment that they may need. It covers wage replacements so there are temporary disability benefits that an injured worker may be entitled to. If someone is off of work completely, that equates to two-thirds of what their normal pay would be, what their average weekly wage would be, but it is capped by year. So once you reach a certain threshold, it stops. So injured workers can sometimes earn far, far less on work comp than they would ordinarily. So that's another incentive to get back to work quickly. It also offers permanent disability benefits. If there's a permanent impairment at the end of their treatment, if there's disfigurement, it offers monies for disfigurement. And in certain cases, if they're not able to return to their usual job, it can offer vocational rehabilitation as well. Okay, and so if someone is injured at work, what do they do? The first thing they would need to do is immediately report it to their supervisor. The employer is required to file what's called a WC1 form within seven days of becoming aware of the work injury. So that gets the ball rolling with the Department of Labor. If the injured worker is concerned that the claim has not been filed by the employer or there's a delay of some sort, they can file their own WC5 form and that will also get the ball rolling at the Department of Labor. From that point on, the insurance adjuster will handle the claim and just work with the injured worker on finding out who their medical provider is, what medical treatment they need, and get them on track to getting healthy and getting back to work. Can they go to any doctor? They do have a choice of doctor that they go to. The department also allows a one-time change of physician if the injured worker is not happy with the doctor that they initially selected. After that one time, though, then it does require approval, either by the insurance adjuster or by the department. And the reason for that is we just don't want people doctor shopping. Okay. And where do you come in? I usually come in only in extreme cases. So usually the adjusters, as I mentioned, they're very hard workers. They know their job. They get it done well and they're very kind, caring, giving people. They can normally handle the vast majority of work comp claims. The only reason that I come in is if there's, for some reason, a more serious injury that requires attention, a more complex case, or there's concerns about malangering or something else not going quite right. In the case, maybe it's not moving on the trajectory that would normally be expected. And so a lot of times I'll be called in to review the file, just have a clean set of eyes on something to see where the case is at and how we can get it moving. So if someone just hurts their back, a typical thing they're picking up is something at work and they have a lumbar sprain, sprain, which is basically a low back injury, what do you usually expect to see in the course of their treatment and rehabilitation? If it's just a lumbar sprain, I would expect that they would go see their doctor right away and perhaps their doctor would work with them on getting some restrictions for their current job if it exceeds their physical limitations. So they might have some weight lifting restrictions or be able to sit and stand throughout the day, depending on what's going on with their condition. This is hopefully to help rest the injured area. And then also we would expect to see some medical treatment, maybe a little bit of physical therapy. Sometimes we do see massage, acupuncture, there are various modes, methods that work for different people. So we see those a lot early on in the case. After several months though, and usually red flags start popping up around the six month mark for me, if someone's condition is not getting any better, then it's a signal to me that something else is going on in the case. Either they've not been diagnosed correctly, perhaps they need some diagnostic tests to rule out maybe they need a shoulder surgery or some other treatment that they're not currently receiving in order to get better. But I would expect that those passive modalities that I mentioned would kind of run their course after about six months. And at that point the injured worker should be able to go back to their usual job. Okay, and so would chiropractic fall into that passive modality? Absolutely. Okay, so now, and so it's okay if they get passive treatment rather than active treatment like passive meaning chiropractic, massage, acupuncture when someone is doing the work on the injured person rather than them actively doing the work like with physical therapy? Yes. Okay, and so is there a limit to the amount of passive treatment that they're allowed under work on? It's really on a case by case basis. There's no set limit, but as I said we do become concerned when it starts to go on for an extended or protected period of time without any signs of improvement. That becomes an issue that we want to look at and I would assume the injured worker would want to look at it as well because the goal is to get better. Okay, so what is the standard? Like they have to show that the treatment is medically necessary or what is that the standard or is something else? Sure, so the statute provides that it has to be reasonably needed for the work injury. Okay. And that standard is a little bit loose in its interpretation and I think it naturally has to be because all injuries are different, all people are different, people heal at different rates. And so there is quite a bit of flexibility. We do see however, for example, since we have been using back injury as an example, we'll see people go in for treatment for back injury. And then when we start looking at their medical records, we'll see that the chiropractor is also treating the neck. That becomes problematic for us because that is something that should be built if there is a problem, something that should be built under personal medical as opposed to the work injury. So it really takes quite a bit of time to sift through and sort all those things out. Does the claimant have the burden of proof to show that the treatment is medically needed? The claimant and the medical doctor that they're working with do have to show that the treatment is reasonably needed. So once a provider, an attending physician for the injured worker determines that certain treatment is needed, let's say chiropractic treatment, for example, they would have to submit a written treatment plan to the adjuster for review. The adjuster has seven days to approve or deny it. Sometimes they simply request clarification. They need a few questions answered as to why the treatment is justified. So at that point, if it's not approved, they'll send a letter to the doctor saying, hey, we would like you to answer these few additional questions. And it's denied pending your answer to these. Right. And honestly, nine times out of 10, the doctors don't even respond to us. So the treatment is denied. And the person left holding the bag, then, is the injured worker who's not getting the treatment that they need. OK. And so do you come in there where there's a denial? Yes. So I help the adjusters. When I'm on a particular file, I do help the adjusters review to determine whether treatment is reasonably needed. I'm not a doctor. So we also rely very, very heavily on the experts involved in the case. We'll oftentimes retain what's called an independent medical examiner to review a file, and he'll review it, determine what the diagnoses are, and what treatment is reasonably needed for the work injury. And we'll kind of try and follow the outline that the doctor gives us. OK. And I'll ask you a bit more about that after our break. And so we're going to take a short break now. I'm Katharine Norr. This is much more on medicine on the ThinkTech Live Streaming Network series. We're talking with attorney Natalie Pettit about how workers' compensation works. Aloha. My name is Victoria, and I'm a host at the Adventures in Small Business. This is a collaboration between US Small Business Administration, Hawaii District Office, and its partners, where we showcase the stories of local entrepreneurs and small businesses. Talk about how to start a business. Talk about great tips for small business owners. Please join us every Thursday, 11 AM at ThinkTech Hawaii. See you soon. Mahalo. Aloha. My name is Wendy Lo, and I want you to join me as we take our health back. On my show, all we do is talk about things in everyday life, in Hawaii or abroad. I have guests on board that would just talk about different aspects of health in every way, whether it's medical health, nutritional health, diabetic health. You name it, we'll talk about it. Even financial health. We'll even have some of the Miss Hawaii's on board. And all the different topics that I feel will make your health and your lifestyle a lot better. So come join me. I welcome you to take your health back. Mahalo. We're back. We're live. I'm Katharine Norr. It's much more on medicine, on ThinkTech, live streaming network series, and we're talking about how workers' compensation works. We're with Natalie Pettit and Natalie, what is an independent medical examination? An independent medical examination is an examination within experts in his particular field that the insurance carrier pays for. Now, this does not mean that the opinion is bought or purchased or influenced in any way by the insurance carrier. It's simply that the carrier is requesting this and therefore they're responsible for the bill. The injured worker is not responsible for the bill because that would be unfair. With an independent medical examination, there are a number of providers. We have some really, really excellent, excellent experts here on Oahu. There are also some that are very, very conservative in their opinions. And so we usually try to exercise and get opinions from the ones who the injured worker can also have a buy-in from and their attending physicians can have buy-in from if they're represented by an attorney. Their attorney can have buy-in from. Our goal with an independent medical examination is to identify areas where maybe some tests the injured worker hasn't had or some treatment that the injured worker hasn't tried to see if we can help improve their condition. Also if there are any new ideas, a fresh set of eyes on something that can get the injured worker back to work, identify any problems or irregularities. And also to provide, as I mentioned earlier, one of the benefits under work comp is if there is any permanent impairment. And so the independent medical examiner will help rate the permanent impairment of the injured worker when the claim is ultimately ready to be resolved. When you say buy-in, are you saying agreement in terms of selection or I'm not sure what you meant by that. Sure, so the statute in work comp provides that the employer gets to select the independent medical examiner. But in practice, our goal is to work with people to try and bring the claim to resolution. So we don't want to make it an adversarial system where people are digging their heels in on both sides at both ends. So we usually do try and get agreement by the other side as to which provider they will see in order to move the case along. That way, as I said, both people feel like they're being heard, that they have buy-in into the process. And that way we can trust the result on both sides. Okay, and so do you find that the claimant and their attorney that they will agree with what the IME doctor has to say? It depends which attorney we're working with. For the most part, yes. Okay. We do try and work together. We're a very small legal community here on Oahu in Hawaii. And we do try to work together. So we try and find mutually agreeable providers. And when we do, and that doctor renders an opinion for the most parts, both sides, whether they like it entirely or not, are willing at least to concede that the doctor is credible in his opinion. And we use that in order to move the case forward and resolve the case. Okay, so what about medication? I know that there is an opioid crisis in the United States. And is there a concern with opioid use in relation to work comp claims? There is a tremendous, tremendous concern. And it's not just a concern, it's a reality. So for example, there is a particular provider in California who was convicted, actually pled guilty to workers' compensation fraud in California. And ended up having to pay a large fine and was also subject to potential incarceration. That doctor is still practicing here in Hawaii. Really? Yes. That's kind of scary. It is very scary, and we see the same practices and trends in his case handling here in Hawaii, in his treatment of injured workers. That he was doing in California as well. In addition, one example I frequently use, it's been a couple of years now, since I've had this case. It has since resolved, but it's such a sad story. We had a girl who was in her 20s, she's a young girl. And she sustained a simple back strain. She was picking up a chair for a display set up that she was doing. It was just an aluminum beach chair and moved it, and sustained a back strain as a result. When I did a background check on her, she had prior convictions for drugs. She was already at risk. She went to a provider and they started prescribing narcotic medication to her. And she was not represented by an attorney, so I had the opportunity to speak with her personally. She shared with me that the doctor would hand her bags. This is her words of bags of drugs when she would leave his office. I tallied the cost to the carrier. And for one month's supply, they were trying to bill $30,000. So I don't know what kind of provider in their right mind would send a young girl off with bags of drugs when she clearly has propensity to not use them correctly. Well, okay, that is a horrible story. Yes. What about providers who fill the prescriptions in the house? Is that a concern to you? That is a concern. We have here in Hawaii so many options for filling prescriptions. You can fill them at the grocery store. When you go grocery shopping, you can go to the drug store. There are all sorts of pharmacies around. There's a lot of hospitals that have pharmacies that you can fill out. There are lots of available sources to fill prescription drugs. When a provider starts filling them in house, that's a red flag to me. We oftentimes see that the provider is prescribing compound medications, which are mixed with just a slightly, slightly different formula. But because they do that, they can pull it outside of the work comp. We schedule and basically set their own price. That becomes a problem, and we do see exorbitant prescription bills come in when they're prescribed in-house versus when they're filled out of pharmacy. Okay, because there's a pharmacy on every corner around here, so that doesn't make sense. Indeed. What about in-house drug testing? Because I know that you sometimes see that on treatment plans. We do. So it's fascinating. People who are taking prescription medications, I think it's appropriate for them to have periodic random drug testing. Usually we see that maybe once a quarter. But with more emphasis being placed on prescription drugs and investigating the abuses of prescription drugs, we have seen certain providers begin to offer more drug testing in-house, where they didn't use to offer that previously. And we're starting to see the same types of patterns where they will draw the lab work in-house, either the urine screen or if it's a blood screen, they'll do that in-house. They'll ship the sample off someplace on the mainland. And then when we get the bill for that at the end of the day, it's often much, much more than what it would have been had the injured worker drawn to a lab to have the test done locally. Why would you test for drugs? Well, we test for drugs for a variety of reasons. Number one, we want to make sure the injured worker is in fact taking the drugs that they're prescribed. And number two, we want to make sure that there's nothing else in their system that would be contraindicated that would cause a problem with their prescription drugs. So for example, if someone is taking illicit drugs, cocaine or meth, that's obviously something that we need to know in that situation. We probably would have their provider stop the prescription drugs until they can get stabilized and get off of the illicit drugs. Okay. So when you come into the picture and it's a complicated situation, is there sometimes something about the case seems like there might be some lingering or maybe they're able to do things that they claim that they're not able to? That happens on occasion. I do want to emphasize and I think we started this segment out initially that adjusters and injured workers can mostly for the most part in the vast majority of cases work together and it's problem-free. So the cases I'm talking about now are that we're shifting into our cases that are unusual, but you're right. They do occur. We do see some fraudulent claims and we do see some lingering and that has to be addressed. So we do monitor people's social media and we do background checks and if there's an indication, sometimes we'll get tips from coworkers that they're engaged in certain activity. If there's an indication that they're exceeding their limitations, if you're saying you can't perform your job and you need to be on disability because let's say you have a back injury and you're not able to lift, but we see you out hiking and engaged in some sort of vigorous activity or out fishing, you have a shoulder injury and you're out fishing. Those types of things become red flags. Okay and we are running out of time, but I wanted to ask you to tell me what the most egregious situation you've seen like that was. Oh my goodness. I hesitate to say, but we did have one girl who had injured her back at work lifting a heavy box of product. She worked at a bar and she was lifting, I think, in any event. She was off work for the work injury. And actually it was an injury to her neck, I remember, because she was constantly wearing a neck brace. Every time we saw her she had this neck brace on. We discovered that she was working on the big island while she was on disability from employer as a pole dancer and she was really gifted. We actually sent an investigator out there. He took one of her classes, she taught pole dancing. They took one of her classes, filmed her the entire time, and she had some moves. Okay, so Natalie, what would you like to leave us with in terms of what we should take away from this about work comp? That the system should not be as complicated or as confrontational as it can sometimes be. It's really easy to work with people. The goal, I think that the employers share and that the injured workers share is that we want to give people the medical treatment that they need in a timely manner so that they can get back to work and be productive citizens. Okay, thank you. Okay, we're out of time and we'll have to wrap it up. I'm Catherine Norr. This is much more on medicine, on the Think Tech live streaming network series. We've been talking with attorney Natalie Pettit about how workers' compensation works. Thank you for joining us today. Thank you to our broadcast engineer, our floor manager, and to Jay Fidel, our executive producer who puts it all together. Please join us for a future Think Tech production.