Post-traumatic stress disorder (PTSD) claims can be particularly tricky due to the shifting nature of the diagnosis. Greater awareness around mental health is helpful, but there are several factors that greatly impact a patient’s outcome. The challenge with PTSD claims is in identifying the circumstances that could lead up to a future diagnosis. Unlike a physical injury, PTSD is not something that gets diagnosed on day one of a claim; rather, it develops over time.

Here are a few examples of the types of PTSD cases Sedgwick’s claims teams may see, and how we respond:

• Margaret, a retail pharmacist who was robbed at gunpoint while working at the pharmacy, has been off work ever since the incident. She was not leaving her home and not driving her car at all secondary to feeling unsafe. Sedgwick’s behavioral health solutions (BHS) team was engaged to provide support and immediately started direct communication with Margaret and her treatment provider to explore and provide trauma psychoeducation and coping mechanisms to address her anxiety and agoraphobia. The team worked with Margaret’s care provider to develop a gradual return to work plan alongside therapy appointments to acclimate her slowly and supportively back into the workplace.
• Kathy is a flight attendant who was physically assaulted by an irate passenger. Kathy sustained physical injuries, including a concussion and suffered from Acute Stress Disorder, eventually turning into a PTSD diagnosis. Sedgwick’s BHS team helped coordinate the appropriate care for Kathy’s physical injuries and kept in contact with her neurologist. We were also able to connect Kathy with an EMDR trauma-focused therapist two times a week to address her initial symptoms with early action. Kathy received psychoeducation and coping training, and her care teams coordinated regularly to provide ongoing support, access to care and the appropriate health services to provide a safe return to work opportunity. Eventually, Kathy was able to successfully return to work after some test flights and a final evaluation from her care providers.
• Insurance investigator Bob was injured in a motor vehicle accident. His car was struck by another car on a two-lane highway, and the other car then collided with a truck that was following Bob’s car. Although Bob survived the crash with minor injuries and some neck strain, the other driver was killed instantly in the crash and Bob witnessed the traumatic scene when he left his car to try to help the other driver. Sedgwick’s BHS team was engaged quickly to find a trauma/EMDR therapist and a psychiatrist to address Bob’s severe stress symptoms following the accident. This psychoeducation gave Bob guidance on case-specific self-help techniques to incorporate into his life while he waited for a referral for clinical care and return to work readiness preparation. The BHS team stayed engaged with Bob’s care providers throughout his treatment.

In each of these examples, Sedgwick’s behavioral health solutions team followed several key guidelines to ensure effective PTSD treatment with positive outcomes.

Early identification

People affected by PTSD have a better chance of recovering and returning to work quickly if early intervention steps take place, rather than waiting for the person’s symptoms to introduce themselves. In these cases, patients may eventually report heightened and fearful responses to everyday stimuli, re-living the event in their thoughts or dreams, or experiencing survival guilt about the event. By the time patients report these trauma symptoms, they’ve lost crucial recovery time. Some patients may not even report their symptoms at all.

There are different ways to determine how early PTSD may be a factor in a claims case. Sometimes, care providers can evaluate the case based on the description of the traumatic event – common cases include those involving assault, mass casualty events or large accidents where people witnessed traumatic events at the scene. Providers can anticipate the need for mental health support so that if PTSD symptoms begin to form, patients are already receiving counseling, so the mental health impact won’t be as severe.

As claims technology improves, artificial intelligence (AI) models can assist claims services and case management experts in determining early ways to identify claims that are a more complex clinical circumstance. AI technology has improved to begin to recognize potential PTSD patterns earlier in the life cycle of claims and can flag these claims to management experts much earlier. With further evaluation, claims providers can intervene and initiate PTSD care steps sooner, reducing the overall time and cost of care while getting the patient back to work sooner and healthier.

Right providers, right treatment plan

It’s important to identify PTSD symptoms as early as possible, but it’s equally important to ensure that the patient is getting the right kind of help for their unique circumstance. Just as a patient wouldn’t visit a spine surgeon to address a cardiac issue, Sedgwick’s BHS team helps ensure that patients are referred to the right provider with the right experience.

Providers are not created equal in the psychiatry space – each mental health expert has their own specialties, fee schedules and insurance guidelines. In the above examples, our team worked with care providers to match each example PTSD case with multiple mental health specialists with specific expertise to match the patient’s needs and ensure providers accept workers’ compensation plans.

What’s most encouraging is that there are many resources available for people that experience traumatic events on the job, especially with the right care team and protocol helping process their claims. There are many treatment options available to address PTSD symptoms in a therapeutic environment where patients can continue to live their lives and eventually reengage with society and their job.

To learn more about Sedgwick’s managed care services, visit our website.