By Healthesystems
Complex claims in workers’ compensation are defined by two primary factors – cost and duration – exceeding those of typical claims. The prevailing consensus among industry leaders is that the incidence of complex claims is increasing, and over 50% of surveyed stakeholders think that complex claims are a major challenge for the industry.
The factors that can lead to claim complexity are multiple, intricate, and often overlapping. Some are more likely than others to cause complexity. Depending on the claim, factors associated with and/or contributing to high-cost claims may be unavoidable. But understanding which factors influence the course of a claim is key to identifying and mitigating risk.
Common influencers of claim complexity and/or costs include:
#1. Type and Timing of Treatment
Surgery and physical therapy both increase the chances that a claim will enter complex/high-cost territory. A Workers Compensation Research Institute report asserts that surgery, which carries a high unit cost, increases the chances of a high-cost claim by 335%. Meanwhile, physical medicine, which is low cost but high utilization, increases the chance of a complex claim by almost 250%.
Patterns of late resource-intensive are the largest single factor associated with high-cost claims, according to WCRI. Claims with one or more months of resource-intensive care after 12 months are 35 times more likely to be high-cost claims, while claims that receive resource-intensive care within the first four months are 5.7 times more likely to become high cost.
#2. Discontinuity of Care
Injured workers often require a variety of medical services, which can inevitably mean care from multiple providers. In some circumstances, injured workers visit one provider for an initial visit and then are referred to specialists and/or in-network providers. Whatever the reason, disruption in the continuity of care influences claim trajectory. According to WCRI, claims that received care from four or more healthcare providers during the first three months of treatment are 50% more likely to become high-cost claims than identical claims with three or fewer providers.
#3. Injury Type
Non-catastrophic – but still serious – injuries such as burns, fractures, dislocations, and neurological injuries are common in workers’ comp. Claims for these types of injuries are often straightforward, but they can become complex and may be more likely to do so depending on their precise nature and the body part involved. For example, according to WCRI, fractures between the ankle and hip and fractures of the spine make claims 4-5 times more likely to escalate in cost than other fractures.
#4. Comorbidities
Comorbidities, such as hypertension, obesity, and diabetes, have become an increasing concern in workers’ comp over the past decade. Sixty-three percent of surveyed industry professionals believe that comorbidities are the top barrier to injured worker recovery and 60% selected comorbidities as their most concerning claim complexity. WCRI found that comorbidities increase the likelihood that a claim will become complex by 33%.
#5. Mental Health Conditions
Mental health conditions in workers’ compensation can present as a primary diagnosis, a co-existing condition, or both. Post-traumatic stress disorder (PTSD) is a compensable condition in many states, particularly for first responders. Other mental health conditions, such as anxiety and depression, often become part of a claim, either as a secondary diagnosis resulting from the initial injury or a pre-existing condition. Claims with a mental health component are 2.5 times more costly than other claims, according to NCCI.
#6. Social Determinants of Health
Social Determinants of Health are conditions outside of the workers’ compensation and/or healthcare system that affect health risks and outcomes. These include factors such as housing, food and nutrition, transportation, social and economic mobility, education, and environmental conditions. SDoH include behavioral health issues, such as drug or alcohol abuse, which can also impact worker recovery and cause a claim to become complex. Analysis by Healthesystems found 80% of claims included at least one SDoH and WCRI found that 8.5% included substance abuse.
#7. Medications
Long-term opioid use is associated with temporary disability duration more than triple the duration of claims without opioid prescriptions, according to a WCRI analysis.As opioid use has decreased, prescriptions for other drugs, such as gabapentinoids and benzodiazepines – which have potential for abuse – are more common. Utilization of high-cost dermatologicals, migraine medications, and specialty drugs are also on the rise and driving up claim costs.
#8. Out-of-Network Care
Out-of-network care is known to be a cost driver in workers’ compensation and a recent study from the Texas Division of Workers’ Compensation found that the average cost for lost-time claims was $6,851 for in-network claims and $8,645 out-of-network claims.But the impact of out-of-network care extends beyond dollars and cents. Injured workers who received in-network care had a 93% return-to-work rate, as compared to an 84% return to work rate for those who receive out-of-network care, and patient satisfaction levels for in-network care were 63%, as opposed to 55% for out-of-network.
#9. Attorney Involvement
Over 61% of industry stakeholders cited litigation as the top workers’ comp challenge in our 2025 Workers’ Compensation Industry Insights Survey, and in subsequent interviews survey participants strongly expressed their opinions that claims complexity and attorney involvement are inextricably linked. A 2024 study from WCRI did conclude that attorney involvement increases lost time days by 284% and inflates expense payments by 200%.
Want to Learn More?
To learn more about complex claims, including mitigation and management strategies, read our RxInformer magazine article, Common Exceptions: The Rising Incidence of Complex Claims in Workers’ Compensation.
