Specialty Solutions Spotlight: Why Prosthetic Claims Are Among the Most Complex in Workers’ Compensation

What do adjusters need to know to manage prosthetic claims with confidence? 

Prosthetic claims rank among the most challenging to manage. They demand ongoing clinical oversight, coordination across multiple providers, and long-term planning well beyond the initial device fitting. These claims are about more than the device itself since they represent an injured employee’s path to regaining mobility and rebuilding their life. With the right support and strategy, prosthetic claims can restore function, independence and even return-to-work opportunities. 

What Makes Prosthetic Claims Challenging 

Managing prosthetic cases goes beyond just approving a device. These claims involve lifelong medical needs and come with unique complexities, including: 

• High upfront and ongoing costs for fitting, refitting, and replacement
• Varying levels of patient engagement and comfort with device use
• Multiple stakeholders—prosthetists, physicians, therapists, and case managers—who must stay aligned
• Long-term lifecycle management, as most prosthetics require updates or replacement every few years

How You Can Improve Outcomes

1. Start early with clinical oversight 
   Early clinical evaluation helps prevent delays and ensures the first prosthetic fitting is appropriate. Request complete documentation from providers upfront and engage specialty partners early to help streamline approvals.
2. Prioritize fit and function 
   A poor fitting device can lead to complications, secondary injuries, and added costs. Make sure providers document proper fit and function benchmarks to support long-term recovery and smoother return-to-work transitions.
3. Engage the injured employee
   Injured employees who understand their prosthetic options and participate in decisions are more likely to adapt successfully. Look for signs of engagement in provider reports and encourage communication that keeps the injured employee involved in their recovery journey.
4. Plan for the prosthetic lifecycle 
   Most prosthetics have a functional lifespan of three to five years, with adjustments often required sooner. By anticipating replacement and upgrades, you can avoid surprises and keep claims on track financially and clinically.
5. Foster collaboration across the care team 
   Consistent communication between prosthetists, physicians, therapists, and adjusters is essential. Establish regular check-ins to keep everyone focused on the same recovery goals and timelines. 

Helping Injured Employees Move Forward 

By focusing on early documentation, timeline tracking, and strong provider partnerships, you can reduce administrative hurdles and avoid unexpected costs and deliver better outcomes for injured employees. A robust specialty network gives you access to providers who can match each injured employee with the right device for their medical, occupational, and lifestyle needs. 

Catastrophic injuries can bring feelings of grief and finality. Prosthetic care  supports the full recovery journey. Helping an injured employee see themselves using a prosthetic and resuming familiar routines can ease the emotional adjustment and encourage lasting recovery. 

At Apricus, we work with you to identify and procure the devices and support services needed to ensure injured employees receive the prosthetic equipment that helps them live healthy, productive lives. On average, our program delivers 37% cost savings on orthotics and prosthetics while maintaining a 97% injured employee satisfaction rate. We also prioritize responsiveness, with care coordination initiated within one hour of referral. These results reflect our commitment to both financial stewardship and a better experience for adjusters and injured employees alike.

This information is meant to serve as a general overview, and any specific questions should be fully reviewed with a health care professional or specialty service provider.

To make a referral for orthotics and prosthetics, physical therapy, and other services, call us today at 877.203.9899 or send an email to apricus.referrals@enlyte.com.