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Explainable AI in Workers’ Compensation: A Practical, Ethical Guide for Claims, Legal, and Medical Professionals
The MedLegal Professor’s Technology Lab™ Series
By Nikki Mehrpoo, AIHI, AIWC, AIMWC – The MedLegal Professor™
Featured on WorkersCompensation.com | Powered by MedLegalProfessor.ai
Discover how explainable AI protects attorneys, adjusters, and claims teams from risk. Real-world guidance, ethical tech use, and compliance strategy. Start using AI the right way.
From Overwhelm to Empowerment: Making Sense of AI in Workers’ Compensation
Artificial intelligence (AI) is rapidly becoming a cornerstone of the workers’ compensation system. Yet many professionals—including claims adjusters, attorneys, nurse case managers, risk managers, and employers—still ask:
What does AI really do in workers’ comp?
Will it help me or eventually replace me?
How can I ensure the tech is fair, legal, and transparent?
These questions are not signs of resistance. They are signs of leadership. The truth is: You do not need to become an engineer. You need to become an ethical, informed user.
👉 Start here: Ask your vendor or IT lead, “What exactly does this AI tool do, and can I see a sample of its decision-making?”
This article breaks it all down with clarity, practical examples, and real-world legal-medical relevance.
What Is Explainable AI and Why Does It Matter in Workers’ Comp?
Explainable AI (XAI) is a form of artificial intelligence that allows humans to understand, audit, and justify the logic behind an automated decision. It shows its work, just like we teach professionals to do in court, clinical review, and compliance audits.
AI Tools That Work for You, Not Around You
Non-explainable AI: “Flag this claim.” No reasons. No trace.
Explainable AI: “Flagged for X due to pattern Y in Document Z” with a full logic trail.
Benefits of Explainable AI:
Verifiable reasoning
Audit-readiness
Legal defensibility
Early error detection
Ethical alignment
🛠️ Practical Tip: Look for tools with a “click-and-trace” feature. You should be able to click on any AI-generated flag or recommendation and see exactly what triggered it.
“Invisible AI makes visible mistakes.”
How AI Is Already Shaping Claims and Compliance Workflows
AI is already being used to:
Prioritize incoming claims
Flag potential fraud
Evaluate medical necessity
Auto-deny or authorize treatment
Recommend settlements
These systems are influencing everything from litigation risk to patient outcomes. That is why understanding them is not optional.
“When you cannot explain AI, it is not just a tech issue. It is a liability.”
🛠️ Practical Tip: For every AI recommendation, ask: “Can I explain this decision to a judge, regulator, or injured worker?” If not, the system may be putting your license or your case at risk.
The AI + HI™ Model: Combining Automation with Human Oversight
At MedLegalProfessor.AI™, we use the AI + HI™ framework, where AI means automation and HI means human intelligence—judgment, ethics, and accountability.
“You don’t need to code it. You need to control it.”
AI + HI™ = Faster results + Ethical review + Trustworthy output
🛠️ Practical Tip: Assign one “AI reviewer” per team. Their job is to check if outputs align with legal, medical, and operational standards. No AI tool should be left unsupervised.
Why Explainability Is Now a Compliance Requirement
When AI is used to:
Deny treatment
Refer a claim to Special Investigations
Auto-settle indemnity exposure
Flag a doctor for overutilization
…it is not just automation. It is adjudication.
Leaders and their teams across the industry must understand and be able to explain the AI’s involvement. Whether you manage a claims desk or legal practice, you need to know how the system reached its conclusion and what role humans played.
🛠️ Practical Tip: Build AI literacy into your compliance strategy. Ask during training: “Who can explain this decision? Who signed off? Is it traceable?” That question builds a culture of ethical accountability.
Five Questions Every Claims Leader Must Ask Before Using AI Tools
Before you trust a claims triage tool, automation engine, or predictive model, ask:
Can I clearly explain the decision to a peer, claimant, or regulator?
Can I see the underlying documents or data it used?
Can I correct or override its output if needed?
Does the vendor allow human review of all outputs?
Is there an audit trail that documents the full process?
If the answer to any is “no,” you are operating without a net.
🛠️ Practical Tip: Post these five questions at every review desk. Use them as a readiness test before onboarding any system.
Common Red Flags: When AI Tools Create Legal and Ethical Risk
Avoid tools that:
Use mystery “scores” with no justification
Make irreversible decisions
Offer “just trust us” logic
Lack downloadable logs or reports
No human judgment? No human justice.
🛠️ Practical Tip: In every vendor demo, ask: “Can you walk me through how I would audit or override this system’s decision?” If they hesitate, you should too.
Case Study: Avoiding a Lawsuit With Explainable AI
A national TPA flagged a “high-risk” claim using AI. A senior reviewer noticed that the tool had factored in ZIP code and age—potentially discriminatory inputs.
Because the system was explainable, the logic trail was visible. They corrected the recommendation, documented the oversight, and avoided liability.
Result: No lawsuit. No bad press. Just responsible tech and strong human review.
🛠️ Practical Tip: Run random monthly audits of AI-flagged claims. This helps detect hidden bias and ensures your system holds up under legal review.
Checklist: What to Look for in an AI Tool for Legal or Claims Use
Your AI tool must have:
Transparent training data and logic
Explainable recommendations
Human override or approval checkpoints
Role-specific customization (legal, clinical, claims)
Downloadable audit logs
Responsive support team
🛠️ Practical Tip: In your tool vetting spreadsheet, add a column: “Could I explain this to a judge?” Rate each vendor on that question alone.
Start Here: Simple Ways to Make Your Team AI-Ready Today
Designate an AI ethics reviewer per department
Include “AI explainability” in every vendor contract
Train teams on your five-question audit
Create escalation protocols for AI-generated errors
Use human-in-the-loop workflows in every automation process
🛠️ Practical Tip: Empower every team member—legal, claims, or clinical—to say: “I do not trust that AI output. Let us review it together.” That one statement can protect lives, licenses, and livelihoods.
FAQ: Explainable AI in Workers’ Compensation
What is explainable AI in workers’ compensation?
AI that provides clear reasons for its decisions, like why a claim was flagged or denied.
Why does it matter for adjusters and attorneys?
It protects legal defensibility, promotes fairness, and reduces the risk of bias or error.
Can AI replace human adjusters or reviewers?
No. Explainable AI supports professionals but cannot replace ethical judgment.
How do I know if a tool is safe to use?
Use the five-question test. If the system lacks traceability or auditability, it is not safe.
🔍 MedLegal Insight™
“AI can help you get started. AI can help you move faster. But only you can make it right, legal, and worth trusting.”
This is not about tools. This is about trust.
🛠️ Practical Tip: Use this quote in your next team training or compliance meeting. Let it set the tone for how you use automation with judgment, not overconfidence.
📢 Take the Next Step: Empower Your Team with Ethical AI
Still using tools you cannot explain? Time to upgrade.
👉 Visit MedLegalProfessor.AI to explore:
📧 Contact The MedLegal Professor at Hello@MedLegalProfesdor.AI
🎓 Want to learn more? Join us live every Monday at 12:00 PM PST
The MedLegal Professor™ hosts a free weekly webinar on AI, compliance, and innovation in workers’ compensation, law, and medicine.
🔗 Register here: https://my.demio.com/ref/OpMMDaPZCHP3qFnh?fbclid=IwY2xjawJ7jr1leHRuA2FlbQIxMQBicmlkETF3WFNMZXNzQXBBY2lmakN3AR72dVyzGtHC_7_U_vQz-1d7RKJsn1Pu4I-l-g_thn0wMTEwd_9g32TvWOK4WQ_aem_-7uOCq_tpDxtPiKEsneaxg
🔖 Final Thought from The MedLegal Professor™
These tools will not replace you. They will elevate you.
But only if they are built for ethics, not just efficiency.
We do not fix broken systems with shinier software.
We fix them with smarter professionals, stronger oversight, and explainable AI.
👉 Subscribe to The MedLegal Professor™ Newsletter
📣 Call to Action: Educate. Empower. Elevate.™
Could Electrocuted Foreman who Lost Hand get Jacuzzi, Porch Repairs?
Chris Parker
What Do You Think?
Claims administrators should not automatically deny every request for medically related equipment, even if it seems at first glance far out. But they should consider whether the claimant has provided anything to support his medical need for the equipment.
That issue arose in the case of a foreman for a paving company who was electrocuted at work. It happened when a dump truck hit a power line, causing a live wire to land on the paver he was operating. He suffered severe burns to much of his body, underwent several surgeries, and had to have his right hand amputated.
The claim administrator awarded the foreman workers’ compensation benefits. Later, a physician’s assistant prescribed the foreman a walk-in jacuzzi tub and shower so he could sit down when cleaning himself. The foreman said he needed it because he couldn’t use his prosthetic hand in the shower to safely clean himself without assistance and that he was otherwise in danger of falling.
The foreman’s nurse case manager indicated that his front porch boards needed to be replaced because they were old. They had been deteriorating for over 20 years.
An independent medical examiner found that neither the jacuzzi was not medically necessary. He stated that with "the various means and implements available for disabled persons with limited mobility to reach their back and groin areas, [the claimant’s] continued use of his existing shower is both possible and practical."
The claims administrator denied both requests. The workers’ compensation board affirmed that decision. The foreman took his case to court.
Under West Virginia law, a claims administrator must provide funds for health care services, rehabilitation services, durable medical and other goods and other supplies and medically related items as may be reasonably required.
Should the board have granted the claimant’s requests?
A. No. The evidence didn’t clearly show he needed the jacuzzi or porch repairs as a result of his accident.
B. Yes. Given that he was missing a hand, he needed to be able to sit down when he showered.
If you selected B, you agreed with the court in Carey v. AAA Paving and Sealing, Inc., No. 24-ICA-436 (W. Va. Interm. Ct. App. 06/06/25), which affirmed the board’s finding that the foreman didn’t show he medically needed them.
The court relied in part on the fact that the claimant didn’t explain why the jacuzzi or porch repairs were medically necessary as a result of his injuries.
Further, although the physician's assistant prescribed the walk-in jacuzzi tub and shower, she did not provide information supporting the medical necessity of these requests. On top of that, the independent medical examiner found the jacuzzi was not medically necessary. As to the front porch boards, the foreman admitted they had been deteriorating for over twenty years prior to his injury, indicating that they were disconnected not only from the porch itself, but also from the accident.
Finding the evidence supported the board’s conclusion, the court affirmed that decision.
Journalists Shot, Injured During L.A. Riots
Los Angeles, Cal. (WorkersCompensation.com) – Journalists were among those injured by law enforcement and military members during the efforts to curb protests in Los Angeles.
According to the LA Press Club, more than 30 journalists have been among those injured during the protests against ICE raids. Police have fired less-lethal munitions at protestors trying to disperse them in the pockets of resistance across the city. Since the confrontations began over the weekend, journalists have been hit, pushed and in some cases fired upon, the LA Press Club said.
According to Reuters, two reporters were directly fired upon. Lauren Tomasi, a U.S. correspondent for 9News Australia, was hit while she was reporting on live television. Tomasi had her back to police as the Los Angeles Police Department’s mounted patrol came on to the scene on horseback. Tomasi was speaking into the camera when an officer pointed a weapon at her and fired, video of the event showed. The projectile from the weapon struck Tomasi in the leg.
“I got hit,” she said as she and her cameraman took cover.
Video of the incident went viral. The Prime Minister of Australia, Anthony Albanese, called the incident “horrific.” He said Tomasi was targeted as a journalist and that his country has spoken to the Trump administration about the issue.
In response, the LAPD has said it will be “will be investigating allegations of excessive force and other issues related to LAPD actions during the protests,” but it is not clear if that specifically means the incident involving Tomasi.
A freelancer working for the New York Post, Toby Canham, said he was struck by a projectile while working on Sunday. Canham said he was hit with a “hard and rubbery” projectile that knocked him to the ground and left him with a bruised forehead. The Post published images of the law enforcement officers Canham said fired at him.
According to the press club, at least five of the injured journalists required medical attention.
Others injured over the weekend were a freelance photographer hit in the leg by a 14-millimeter sponge round fired at close range which required surgery to remove; a reporter working for the New York Times who was struck just below the ribs by a projectile; another reporter from Australia who was tear-gassed and struck with pepper rounds while reporting, as well as her cameraman who was hit in the chest; and a 74-year-old writer for the World Socialist Web Site who was shot in the back with a rubber bullet, according to the news website Closer to the Edge.
Reuters said other journalists were tear-gassed, confined in small areas or had their bags searched by law enforcement without their consent.
When asked by Reuters about the injuries to journalists, a White House spokesperson pivoted to risks law enforcement officers and the public face during protests.
“Whenever violent, left-wing rioters engage in lawless behavior, they put innocent bystanders at risk," White House spokesperson Abigail Jackson told Reuters in a statement.
Adam Rose, the LA Press Club’s press rights chair, said the number of incidents involving journalists since the weekend is unprecedented in that city.
It’s not the first time journalists have come under attack and suffered injuries in the U.S. The number of physical assaults on members of the media spiked in 2020 during the Black Lives Matter after the killing of George Floyd, said Press Freedom Tracker. Since then, assaults on journalists have waned. Before the unrest, the web site showed, only a handful of similar cases had been logged in the tracker’s database.