5-7-2018; Gene Keefe on Narcotics/Opioids in U.S. Work Comp Claims; Indiana WC Board Stays on the Cutting Edge of Reporting Technology and more

Synopsis: Gene Keefe on Narcotics/Opioids in U.S. Workers’ Compensation Claims.

Editor’s comment: I/We can’t keep ignoring this one, as it clearly is an 800lb. pink gorilla that is threatening our WC system and lives.

From my perspective, the most addicting substances on this planet are tobacco/nicotine and narcotic/opioid medications.


I am sad to report I have had literally dozens of wonderful clients who passed from an addiction to tobacco/nicotine. These clients left children and grandchildren and families in the lurch, some of these folks smoking during chemotherapy. The scientific and common-sense approach to this substance is simple. If you are using it, please, please save your life and stop. If you are a client or close friend of KCB&A and truly want help to stop, please send a reply.

Narcotic/Opioid Medications

We are in the midst of a national narcotic/opioid overdose epidemic. I personally dislike the term ‘opioid’ because it sounds technical and medical—everyone knows ‘narcotics’ are bad for you and almost uncontrollably addictive.

Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Narcotic/opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. 5 From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.

In 2012, 259 million prescriptions were written for narcotic/opioids, which was more than enough to give every American adult their own bottle of pills. Four in five new heroin users started out misusing prescription painkillers. 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use prescription narcotics/opioids because they are easier to get and use.

“Chronic pain” affects as many as 100 million Americans, more than the number affected by heart disease, diabetes and cancer combined. The prevalence of chronic pain is growing and is likely to continue to do so. As the rate of reported chronic pain increases, it has been accompanied by a rise in the rate of adults reporting the use of prescription drugs for pain, including narcotics/opioids such as OxyContin, Percocet and Oxycodone products.

Workers’ compensation

In workers’ comp cases, spending on narcotics/opioids far outpaces utilization and spending in the group health market. Narcotics/opioids comprise almost 34% of the total drug spend for workers’ comp payers as opposed to about 3% in the group health market. Of the total medical expense for workers’ compensation claims, the cost of prescription medications accounts for 19%, according to the National Council on Compensation Insurance.

The impact on the cost of WC claims is significant. When a workers compensation claim involved any narcotic/opioid, the claim cost averaged nearly $20,000 more than claims without opioids. The use of narcotics/opioids also affected time lost from work. Odds of chronic work loss were six times greater when narcotics/opioids were used.

Please also remember settling a claim involving a narcotic/opioid addict causes the MSA or Medicare Set-Aside Trust value to be gigantic. All parties have to assume the addiction is going to continue and to pay for a lifetime of narcotics/opioids won’t ever be cheap. The MSA cost can easily be much higher than the PPD or impairment value of a given claim—this always confuses injured workers. For this reason alone, the entire U.S. WC industry has to do whatever it can to stop narcotic/opioid abuse and addiction in workers’ comp claims.

How Does the WC Industry Counterattack the Use of Narcotics/Opioids in WC Claims?

First, I recently saw a study of total shoulder replacement surgeries in North Carolina. The docs running the study compared recoveries/complaints with patients that used narcotics/opioids in contrast to those who used traditional ANSAIDS like Extra-Strength Tylenol© or Advil©. The results showed little difference in recovery and complaints. I am sure there were no lasting drug addicts that came from the test group that used traditional ANSAIDS. I strongly hope more similar studies will be published, as the medical/surgical industry starts to refuse to use/promote narcotics/opioids in all patients.

Second, our firm also had a major national client decide on a 7-day rule for prescription narcotics/opioids. They asked me how to “enforce” such a rule. I confirmed three solid tools that can and should be considered in Illinois WC claims.

1.      UR or utilization review is the fastest and easiest method to block prescription narcotic/opioid use. If an employer/insured can get a UR non-cert for continued prescription narcotic/opioid use, it is presumptively correct.

2.      An IME is also a tool to put into the claims bag to use/comment on such prescriptions—the problem with IME’s is the delay encountered in setting and getting the report.

3.      Finally, what this client did by letting everyone know of their “rule” may also “work” to the extent you let the docs/surgeons and others know you have such a rule and refuse to divert from this challenging path. It is hard for IL Claimant lawyers, no matter how dedicated they may be to get such issues rapidly in front of an Arbitrator and force approval of prescription narcotics/opioids.

We are sure our IL WC Arbitrators and Commissioners are well-educated, professional and know what is at stake when they are dealing with prescription narcotics/opioids. These strong hearing officers are generally reluctant to order an IL employer to pay for months and possibly years of prescription drug use/abuse when it comes to narcotics/opioids. Our Midwest hearing officers want injured workers to get healthy after an injury and stay clean and sober when doing so.

WC Insurers and TPA’s Can’t Hide Their Heads in the Sand on this One—Step Up and Start Fighting Narcotic/Opioid Abuse Every Way You Can

With the help of WC insurers and third-party administrators, employers have to play an important role in promoting appropriate use of narcotics/opioids. This can mean early and appropriate return to work to prevent an otherwise simple claim from turning into an expensive and never-ending legacy claim. Companies should look for WC Insurers/TPAs that offer several critical capabilities. These include:

·        Early intervention and Use of Nurse Case Managers: The first few hours after an employee is injured are critical. This is when initial decisions about treatment are made, including what to prescribe for pain. Look for an insurer/TPA with a clinical resource hot line to access nurse case managers that can help assess injuries and direct employees to urgent care or an appropriate network doctor who are positioned to best handle the treatment of injured workers and have a proven track record of successful outcomes.

·        Ongoing Claims insight: At specific junctures throughout the life of a WC claim, the continued use of narcotics/opioids should be evaluated. I like the “hard line” that provides a cut-off date/time. When narcotics/opioids are prescribed, there should be notations in the claim file and a mechanism in place to monitor the types of drugs and duration of use. Use of pharmacy benefit management with aggressive utilization review is critical.

·        Predictive analytics: Strong partnerships between employers and insurance carriers/TPAs are the result of ongoing and meaningful interaction. An insurance carrier/TPA that uses predictive analytics can extract value from a company's claim experiences. This can help pinpoint problems and spur collaborative approaches to develop plausible solutions.

·        Return-to-work programs: Any time an injured worker loses time from work, there is a risk that the individual will never return, leading to total and permanent disability. When narcotics/opioids are involved, the odds of chronic work loss are significantly higher. Aggressive return-to-work programs, therefore, are critical. Employers should look for ways to provide employees with modified job duty whenever possible to get them back on the job.

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Synopsis: Indiana WC Board Stays on the Cutting Edge of Reporting Technology. For answers to your concerns, contact Kevin Boyle, J.D., KCB&A’s Indiana WC Defense Chair.

Editor’s comment: The Hoosier WC Board just announced their EDI 3.1 ROLLOUT to start on 01/01/2019.

The Indiana Worker's Compensation Board (INWCB) will be implementing electronic reporting of workers’ compensation first reports of injury (FROI) and subsequent reports of injury (SROI).  Electronic reporting will be required for all trading partners: insurers, self-insured employers, and third party claim administrators. Mandatory implementation is planned for January 1, 2019.

Electronic reporting will be via Electronic Data Interchange (EDI) transactions using the Claims 3.1 reporting standards adopted by the International Association of Industrial Accident Boards and Commissions (IAIABC). Additional information on the IAIABC EDI transactions for FROI and SROI can be found online at the IAIABC website, http://www.iaiabc.org.

The INWCB has contracted with ISO's Workers Compensation Solutions division, to manage its FROI and SROI EDI reporting.  ISO will be administering registration of trading partners, testing, data collection and submission of EDI data to the State. 

INWCB will provide an enhanced EDI Website that will be available early June 2018. This website address will be provided at that time and will contain the following.


  • Trading Partner Electronic Profiles Registration and Instructions to be completed by all Trading Partners
  • Trading Partner Training Schedule
  • Trading Partner Testing Documentation/Plan. (Note: For Trading Partners that will utilize a Vendor, the Vendor will perform the testing on your behalf)
  • INWCB Claims Release 3.1 Implementation Guide and Requirement Tables
  • EDI Vendors that may assist with EDI reporting
  • Implementation Information that will provide additional information to support the INWCB EDI Reporting Requirements
  • Frequently Asked Questions (FAQ) for EDI
  • Helpful Web Links
  • What’s New: Announcements, etc.
  • Contact us for help at INWCBEDI@iso.com


If you have any questions, please contact the INWCB EDI Support Team at INWCBEDI@iso.com. If you have further questions/concerns, email Kevin Boyle at kboyle@keefe-law.com.