To Suspend or Not to Suspend, That is the Question

An interruption in an injured worker’s life can also interfere with the medical treatment they are receiving under their employer’s Texas Option plan. And this could potentially delay their path to recovery.

Consider this man’s experience: While at work, an employee injured his back and is receiving medical treatment under a Texas Option plan. In the time period he is receiving treatment, he suffers from a stroke, which is unrelated to the original work injury. This employee has not finished his treatment for the back injury; however, he now has to receive treatment for the stroke and is unable to continue treatment for his back at this time. What do we do?

In these situations, the adjuster has challenges to meet: They must determine alternative solutions for the transition to ongoing quality care for the injured employee, and also assist in finding solutions to the personal challenges that can potentially hinder the injured employee’s recovery.

The flexibility offered by Texas Option plans, coupled with the vast experience and assistance from PartnerSource, can help employers navigate this challenge. One option is to suspend benefits. The suspension of the claim stops all benefits for a period of time (most commonly for 30-90 days) until the circumstance that has caused the claim to get off track has been resolved or corrected.

The question then becomes: “To suspend or not suspend?”

In the case of the man mentioned earlier, a determination was made to issue a suspension letter for a period of 60 days to allow for the injured employee to receive treatment for the stroke. After 60 days, the employee was ready to resume treatment for his back injury and the suspension was ended. The employee then continued receiving medical treatment for the back injury until he was released from medical care. This was a positive outcome for both the employee and the employer!

PartnerSource stresses that no two claims are alike, and some circumstances may be medically related while others are not. Some common circumstances where a suspension letter may be considered include:

• Medical records are needed to move forward with the claimant’s treatment, but the claimant has not provided these records.
• The claimant continues with a harmful or noncompliant behavior that needs to stop in order for the treatment for the work injury to be successful (i.e. smoking).
• The claimant needs to receive treatment for a personal medical condition before continuing with treatment for the work injury.
• The claimant did not respond to a warning letter and the employer is not quite ready to issue a full denial on the claim.

PartnerSource can help develop a personalized strategy for these claims to get them on track and help ensure the injured employee the care they need. PartnerSource offers guidance and support to make sure that the best strategy is applied when determining if a suspension is appropriate.

By collaborating with clients and taking a proactive approach in determining whether or not a suspension is the best solution for a claim, PartnerSource can potentially help reduce the amount of denials issued while also creating positive outcomes for the injured employee.