Presumptive Claims: Minimizing Exposure with Early Intervention & Case Management

In our recent “Snowball Effect” blog, we highlighted the importance of early intervention for employee injuries or conditions that can start out minor but become major when not monitored. 

This time, we’re spotlighting early intervention and case management efforts specifically for Presumptive Claims. 

What Are Presumptive Claims? 

Presumptive Claims are unique in that certain employees are presumed to develop medical conditions due to the nature of their work, so workers’ compensation can be filed without needing to prove the cause. 

Who Do Presumptive Claims Cover? 

Currently, 34 states have presumption laws for frontline roles that can include: EMTs, firefighters, police officers, correction employees, and more. 

How Do These Claims Differ from General Medical Claims? 

For general occupational claims, an individual’s injury or condition must be related to a defined incident that happened during the scope and course of their employment. It may only require one visit to a provider, or it may require multiple visits.

For presumptive claims, an individual’s injury or condition is presumed to happen during their employment and will almost certainly need to be monitored beyond a one-and-done treatment. Based on our experience with presumption claims, the employee may report a mild condition or can be reporting an emergency event. 

Some examples: 

• Hypertension found in a routine physical causing a need for time away from work

• Abnormal changes on an EKG that lead to respiratory issues, palpitations or stroke 

• Uncontrolled hypertension and other factors that lead to a stroke

• Coronary artery blockages found by exam or chest pain that led to a heart attack

Any of the above can lead to permanent heart damage, and in rare cases, a possible need for a heart transplant.

Presumptive claims are also unique in that they are usually ongoing and are very challenging to settle. These treatments are costly and subsequently result in increased claim costs. 

What Can Employers Do About Presumptive Claims? 

If you’re among the 34 states with a presumption law covering some or all of your employees, it’s important to already be prepared with a medical triage team you can call on immediately after a claim is filed.

When a client calls us regarding a presumptive claim, our RapidResponse nurse triage team responds immediately. Measures are in place if the situation is emergent. If the situation is non-emergent, the triage nurse will make contact in less than 24 hours. Once the triage process is completed, the employee will be placed in one of our presumption programs and followed by a specialized presumption nurse.

Our Presumption Programs 

Heart & Lung Program (“BADGE”) 

Due to their professions, extreme stress and work conditions, first responders are much more susceptible to cardiovascular and lung diseases. We developed a specialized medical program to address the unique and specialized handling required for these claims: BADGE (Better Administration Dedication Guaranteeing Excellence). 

This program combines disease management with Workers’ Comp case management, enabling the employee to benefit from the latest in quality cardiac healthcare while also receiving a constant source of support and education.

The BADGE Program includes: 

• Medical Director and/or Physician Advisor with board certification in cardiology to assist and direct the medical management team

• Registered Nurses with cardiac patient experience to implement, monitor and assess all presumption claims

• Specialty Facilities and/or Specialty Providers contracted for Workers’ Compensation

• Access to the current Cardiac Care treatments available

• Compliance with state-specific bills and statutes 

To date, BADGE has improved return-to-work outcomes, reduced disability duration, prevented dangerous and costly consequences of inappropriate use of cardiac medications, and reduced the cost of handling presumption claims. 

PTSD (“BADGE Behavioral”) 

Since more than 80% of first responders experience traumatic events on the job and one in three develop PTSD, some states also provide coverage for Post-Traumatic Stress Disorder (PTSD).

This left a need to more holistically support clients, which is why we branched out to establish the BADGE Behavioral program. 

Our team doesn’t just focus on physical injuries—we also have in-house behavioral health nurses and a behavioral health partner system to ensure access to both qualified psychiatrists and psychologists specifically trained in the assessment and treatment of PTSD for first responders.  

If you’re a risk manager who handles presumptive claims for your team, we’d love to talk about how our Early Intervention Team can support you. Feel free to get in touch with me with any questions!