How can ‘Financial First Responders’ Change Assumptions on Low Back Pain?

Article 5 – The Payer  

Ever asked a stranger or new acquaintance what they do for a living only to receive a clever substitute instead of a direct answer? An interventional cardiologist I know tells folks that he’s in the plumbing business. A friend of mine who is an attorney tells others that he "argues for a living." I overheard a barista at a coffee shop identify himself to a customer as the "head grounds keeper." Using a clever substitute when asked your job title offers a humorous way to challenge someone’s initial judgments or bias. An insurance executive started a webinar I attended by saying that he was in the business of "taking people’s money to manage problems they hope will never happen."

For an industry that has recently come under much criticism, the clever substitute was likely delivered to set a positive tone for the rest of his remarks. As a "financial first responder," insurers or payers are called to serve and support when problems arise.  

This series of articles asserts that achieving a successful outcome following workplace low back injury depends on open dialogue and communication to surface biases, challenge assumptions, and address misconceptions or knowledge gaps.  All parties involved -- the injured worker, the provider(s), the payer, the employer, and potentially, the attorney -- make decisions based on their own experiences, which may include individual bias, judgments, and assumptions. This fifth article in the series will explore the payer’s perspective.   

Let’s Just Get Right to It … 

It’s the 500-pound elephant on the table -- the assumption that all workers’ compensation insurance companies question the legitimacy of an injury. It’s a stereotypical judgment that claims adjusters automatically assume not all injuries are genuine. And yet, isn’t it wise to trust, but verify? Challenging assumptions after a workplace low back injury requires lining up the facts.

After injury, the first aspect of patient evaluation is to gather information -- the injured worker’s symptoms, mechanism of injury or causative factors -- and perform an examination to determine a diagnosis. Based upon these initial findings, imaging or further tests may be ordered.

Dr. Doug Burton, MD, an accomplished spine surgeon and Professor and Chair of the Department of Orthopedic Surgery at the University of Kansas Medical Center, is aware of this common assumption.

"A lot of people choose which side they’re going to take. Healthcare providers, physicians, surgeons, claims adjusters, bosses, and so on," Dr. Burton says. "We all make judgments to choose a side."

Exam findings and medical records from the provider play a large role in determining compensability of a workplace injury, documenting its severity, and establishing the necessity of treatment. Brad Brons, a highly skilled claims adjuster who is licensed in 9 states, faces this frequently.

"I regularly assume I’m going to be seen as the bad guy," according to Brons. "There’s a mistrust of insurance companies in general. I know there are cases where that’s true, but I don’t see it with my company."

How Should Assumptions and Judgments be Managed? 

Doing what’s right requires gathering evidence and assembling the facts. The due diligence by a workers’ compensation claims adjuster to interview the injured worker, the employer, the medical provider and review medical records is a necessary step. In doing so, it challenges assumptions and identifies inconsistencies, if they exist.

If concerns arise as the claim progresses, additional investigation may be needed. This may be carried out through surveillance, social media investigation, or medical canvassing to review an injured workers’ medical background and records. These measures may expose details that a claim has been inflated, is fraudulent, or is the result of a pre-existing condition.  

Finger-Pointing Won’t Catch Fraud — Facts Will  

Examining the payer perspective wouldn’t be complete without addressing the issue of workers’ compensation fraud. Previous reports have estimated that 1-2% of workplace injury claims are fraudulent.¹ Fraud has typically been classified by the offending parties: premium fraud (employers) and claimant fraud (employees). And yet, every player -- the injured worker, the provider, the employer, the payer, and the attorney -- can commit fraud.

The Coalition Against Insurance Fraud formed its first-ever Task Force in 2021 to examine the topic of workers’ compensation fraud in the U.S.² The Task Force set out to re-examine and update the long-standing $7 Billion estimate of workers’ compensation fraud annually in the US. Their investigation determined that the amount is roughly five times greater -- approximately $34 billion, $25 billion from employer fraud and $9 billion as the result of employee fraud.

A report published earlier this year by Conning, 2025 Workers' Comp Study: Using Data & AI to Fight Workers’ Compensation Insurance Fraud, estimates that workers’ compensation fraud costs insurers between $35 to $44 billion annually.³ By leveraging data and artificial intelligence (AI), insurers can proactively identify and combat fraudulent activities that have become increasingly sophisticated. Those who suggest fraud in workers’ compensation is uncommon or of little impact may need to address their own misconceptions and knowledge gaps.  

On The Matter of IME’s 

In the event of an injury for which surgery is recommended, it’s standard practice to seek a second opinion from another surgeon before proceeding. Conferring with another health care provider or surgeon affords us professional advice that we deem to be free from bias, allowing us to be confident that we’ve made the best decision.

Makes perfect sense, right?

An independent medical examination (IME) is intended to be an objective assessment of an injured worker’s medical condition, including the treatment needed, whether there’s a permanent impairment and to what degree, and the ability to work in the future. And yet, many injured workers view an insurance company’s request for an independent medical examination (IME) as unwelcome and unnecessary. It’s this unbiased perspective that Brad Brons finds extremely valuable if all the pieces don’t line up on a claim.

"IMEs can be wonderful," he says. "And if the case goes before a judge, most judges will recognize when a doctor is biased. Judges have seen it. They’ve worked as defense or corporate attorneys before becoming judges. That experience is huge."

Mr. Brons has been in the industry long enough to know that some medical decisions should be questioned and sees himself as an ally for his claimants. And if an IME report contradicts the injured workers’ treating physician? Mr. Brons doesn’t hesitate to recommend, "Trust the facts."

Does the Evidence Support an Injured Worker’s Mindset?  

Low back injury can be a complex condition with multiple risk factors, causes, and treatment options that don’t always have successful outcomes. Although multiple factors may be contributory, Tom Slattery, CSP, ARM, Corporate Director of Safety for Norfolk Iron & Metal, points out "it’s that ‘moment of injury’ that many employees identify as causative. An employee may have a physically demanding job but also do physically demanding things at another job or as part of hobbies or family life and yet conclude that this job was to blame for the low back injury."

The initial phone contact that a claims adjuster makes to an injured worker includes questions that may potentially reveal if strenuous activity outside of work contributed to or was causative in low back injury. For injuries without an easily identifiable mechanism of injury such as cumulative trauma, it may be a difficult to challenge an injured worker’s assumptions.

Mr. Brons recognizes this after years of experience as a claims adjuster.

"People have an idea where the injury came from," according to Mr. Brons. "When that’s not validated, they get upset."

Our own stories provide the rationale for what’s happening. They’re our interpretation of the facts. By assembling the facts, feelings, emotions, and stories can be tested. Mr. Brons is familiar with age-related spine deterioration, the high degree of likelihood for incidental findings on low back imaging, and other factors that contribute to the complexity of low back injury. For an injured worker who isn’t knowledgeable of these issues, it can be downright frustrating.

Mr. Bron’s strategy to address this?

His above-average understanding of anatomy and medical conditions and perceptivity are critical to educate and answer questions during conversations with injured workers. Mr. Brons is grateful when providers -- spine surgeons, physicians, physical therapists -- explain the facts and the evidence.

"Some providers don’t have a good bedside manner and lack the willingness to educate," Mr. Brons advises. That’s when things break down."

If an injured worker isn’t given the opportunity to separate the facts from their story, it’s easy to see how resentment and frustration can result.  

The Power of Communication and Consistency 

Returning to work after following low back injury requires communication and coordination. It’s ideal when an insurer and employer share a similar vision to promote return to work strategies and overcome obstacles that might prevent this.

Amy Garrett, PT, DPT, an expert in workplace low back injury at Nebraska Spine & Pain says, "Assumptions without information are not usually helpful, so it’s best when a case manager or adjuster in coordination with the injured worker and the employer are working together to return the injured worker to meaningful work.  Returning an injured worker to light duty, for example, can be so helpful to allow the worker to return to their typical work routine, allow them to socialize with their fellow workers, and move to participate in ADLs that they otherwise may not be doing at home.  Frustrations often arise and significantly escalate if an injured worker is placed on light duty and then asked to do more than this by their employer."  

Getting Back to Work – No Pun Intended! 

Insurers in workers’ compensation must ensure that all parties are operating in the best interest of the injured worker. The treating physician or physical therapist, for example, has an expectation that the injured worker will be compliant with a home program and mindful of lifting restrictions or activity limitations, for example. The provider is responsible to safeguard and protect the worker from potential harm.

Amy Garrett, PT, DPT, points out, "I have seen other healthcare providers assume a certain level of strength in an injured worker which may not be accurate. Just because someone worked in a heavy or medium job does not mean that they don’t have flexibility or core strength deficits that need to be addressed.  Building a strong foundation via exercise is vitally important, even with someone who has worked in a physically demanding job."  

Summary  

As a "financial first responder," insurers or payers are called to serve and support when problems arise. Regardless of the job title, all players involved -- the injured worker, the provider, the employer, the payer, and potentially, the attorney -- can unknowingly fall victim to assumptions, judgment and bias in workplace low back injury. Although these misperceptions may be deeply established, it’s possible to wade through a potentially challenging landscape armed with facts and evidence. Start by gathering medical facts after workplace low back injury, identifying inconsistencies, if they exist, gathering additional information through investigation or an IME, and communicating and coordinating with all parties to validate that a plan for return to work is safe and well executed.

This series of articles concludes with the final article examining the attorney’s perspective. Stay informed!  

References 

1. Leigh JP, Markowitz SB, Fahs M, Landrigan PJ. Costs of Occupational Injuries and Illnesses. Ann Arbor, MI: University of Michigan Press; 2000. doi:10.3998/mpub.16885 

2. Coalition Against Insurance Fraud. Workers’ Compensation Fraud Task Force Report. Washington, DC: Coalition Against Insurance Fraud; 2022. Accessed September 17, 2025. https://insurancefraud.org/wp-content/uploads/WorkersCompFraudAmerica.pdf 

3. Conning, Inc. 2025 Workers' Comp Study: Using Data & AI to Fight Workers’ Compensation Insurance Fraud. Hartford, CT: Conning, Inc.; 2025. Accessed September 17, 2025. https://www.conning.com/about-us/news/ir-pr---ai-workers-comp 

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