The Best Tidbits of News from the Workers Comp Community

 

 
In The Washington Post's On Small Business Blog, MCA's Director of Nurse Case Management, Barbara DeGray, discusses techniques for overcoming feelings of isolation for remote employees. Read more…
 
 
 
Longtime insurance technology executive Mark Stergio has been named CEO and senior vice president of risk management information systems (RMIS) provider Risk Sciences Group (RSG, Atlanta). He will be responsible for continuing the development of a long-term strategy for RSG that focuses on innovative technology, effective analytics and easy-to-use applications that help clients control their overall cost of risk, according to the company.  Read more…
 
 
 
MSP & MIR Program Featured at This Year's  
Worker's Compensation Conference   
 
Bret Cade, Executive Vice President of Sales & Marketing at Gould & Lamb, will be the featured moderator for the 2012 WCI Conferences' full-day program titled "Providing Clarity in a Land of Confusion".  This comprehensive breakout, sponsored by Gould & Lamb, will seek to clarify what has become an extremely complicated process, creating enormous issues for the workers' compensation industry, soon to further expand into the general liability area.  Conference Homepage
 
 
 
Lexis Nexis Lays out Blueprint for HIPAA & ADA Compliant Wellness Programs   
 
 
“Blueprint for HIPAA and ADA Compliant Wellness Programs: Encouraging Good Health Reduces Workers' Compensation Expenses, by John Stahl, Esq. The article "Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based Incentives" in the Journal of Occupational and Environmental Medicine demonstrates how employer-sponsored outcomes-based wellness programs (wellness programs) reduce workers' compensation and other employment-related healthcare costs.” Read more.
 
 
“Court Dismisses Injured Worker's Tort Action Against Carrier for Five-Month Delay in Medical Benefits, by Thomas A. Robinson. A Texas appellate court recently affirmed the dismissal of a tort claim filed against a workers' compensation carrier, another defendant (Southwest) that had provided administrative services, and a physician alleging that the trio were liable for damages under common-law bad faith, statutory bad faith, and fraud theories associated with the carrier's delay of five months in paying benefits to the plaintiff-worker. Read more about this case and other cases involving incarceration, borrowing employer, and causation of injury.”
 
 
“Workers' Comp, Texas Style: A Highly Regulated System in a Pro-Business State, by Stuart D. Colburn and Albert Betts, Jr. Cotton, cattle and oil were the primary economic engines when Texas first adopted workers' compensation. In the 100+ years since, the economy and workers' compensation laws have changed dramatically. The shift from an agricultural to a manufacturing and then to an information based economy changes the frequency and type of injuries sustained at work. Health insurance, Medicare/Medicaid, and disability insurance alter the landscape of both a social safety net for employees and higher costs for employers.” Read more.
 
 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Workers Compensation Around the U.S. This Week

Work Comp Roundup Wants to Meet You at RIMS Booth 1425
The Philadelphia RIMS 2012 Annual Conference & Exhibition will provide a unique opportunity to gather information and resources to help minimize workers comp costs. This year there are sessions for many experience levels and the exhibit hall will have US! Yes! Held at the Pennsylvania Convention Center located on 1101 Arch Street will be Amaxx and WorkCompRoundup at booth 1425.
 
 
“If anyone wants to stop by to say hello or chat about workers compensation issues, I welcome them to do that,” says Becki Shafer, CEO. “For companies struggling with high WC costs, the exhibit hall is a great place to see all the different solutions that are available in the marketplace and attend seminars. One of the best things I did when I began my career in workers compensation was attend RIMS in Atlanta, it was the first conference on Workers Comp I attended, and I was pleasantly shocked at everything that was available — it was like walking through a supermarket of ideas.”

[WCx]

 
 
Learn more about the convention here.
 
 
Keystone Case Management Could Give you a PINCH this Spring
Keystone Case Management is a young company in the Workers’ Compensation World, says owner and president, Kelly Haile, RN, CCM, WCCM. This team of nurses has developed PINCH, a solution that uses employer education and aggressive case management to help employers and injured workers
 
 
PINCH has resulted in a decrease in claim report numbers, out-of-work time and fewer litigated claims, Haile says. “The program has also shown increased satisfaction by injured employees, and employers are delighted at the clear, consistent and timely information that is provided,” she writes.
 
The company recently announced it is a finalist in Dorland Health’s Case In Point Platinum Awards for Workers’ Compensation Case Management and will be hosting a half-day educational workshop for employers April 4th, 2012 in Drexel Hill, PA. For more information contact info@KeystoneCaseManagement.com or (610) 469-NURSE.
 
 
LexisNexis Communities Offers This Week Work Comp In Review
The Workers Compensation Law Community Powered by Larsons on LexisNexis offers several great pieces this week:
 
 
  1. Larson’s Spotlight, found here, focuses on the following recent cases, compiled by Thomas A. Robinson, staff writer for Larson's Workers' Compensation Law:
 
TN: Truck Driver Deviated From Employment by Leaving Truck to Search for Object With Which to Assault Driving Partner
TN: Court Affirms Denial of Benefits Related to Unexplained Fall to Level Floor
OH: Physician's Opinion Was Not Equivocal Where Physician Modified Opinion in Light of Videotape Evidence of Injured Worker's Capabilities
FL: Judge May Not Sanction Homeless Claimant for Failure to Pay Prevailing Party Costs-Failure to Pay Was Not Willful
 
 
  1. Robin E. Kobayashi writes The Sticky Wicket That Is Home Health Care: Why It’s a Hotly Contested Issue in the Workers’ Compensation Arena
 
The article, found here, asks, “An injured employee’s entitlement to home health care is oftentimes a hotly contested issue in the workers’ compensation arena. Home health care issues can vary in nature. For instance, at what point does the marital obligation cease and the paid nursing services begin?”
 
 
The author looks into these types of issues in Nebraska, Iowa, Arkansas, and California.
 
 
  1. Lastly, the LN Community recommends these WC fraud blogs this week:
 
Workers' Comp Fraud Blotter: Mechanic Covered With Grease Claimed He Was Unemployed and Unable to Work,by LexisNexis Workers' Compensation Law Community Staff. Here.
 
“The Case of the Purple Robe … and a Little Motion Day Magic” in Delaware, by Cassandra Roberts, Esq. Here.
 
Missouri: Employer Penalized for Lapses in Prescription Payments, by Martin Klug, Esq. Found here.
 
 
Broadspire Combats Physician-Dispensed Drugs
In a recent release, Broadspire draws from the Workers Compensation Prescription Drug Study: 2011 Update by Barry Lipton, Chris Laws and Linda Li, National Council on Compensation Insurance, August 2011.
 
 
They write, “The price of physician dispensed drugs increased by 300 percent  between 2005 and 2009. In contrast, the average price of medications dispensed by pharmacies grew by only 23 percent during that same timeframe.”
 
 
The company goes on to say the percentage of workers compensation medical costs going toward physician dispensed prescriptions increased to 28 percent in 2009, up from 23 percent in 2008. “Physician dispensed medications have become prevalent in almost every state,” Broadspire concludes.
 
 
To combat this medical cost driver, Broadspire has created the following jurisdictionally specific strategies:
 
1. Through data mining, Broadspire identifies physicians who are dispensing prescriptions from their offices.
2. Targeted communications are sent to these physicians promoting the clinical safety and efficacy offered by Broadspire’s network of retail pharmacies.
3. Safety checks, through network pharmacies, help physicians ensure medications they prescribe are not duplicated by other physicians and that no adverse drug interactions are present.
4. Case managers visit and communicate with physicians to share the Broadspire message and support the use of network pharmacies.
5. Where jurisdictionally possible, Broadspire re-prices provider-dispensed medications to our network pharmacies contracted rate.
 
 
 
 
Texas Department of Insurance – DWC Seeks Public Comment on Amendment Proposals on MDR
The Texas Department of Insurance Division of Workers’ Compensation is accepting public comments on proposals to amend 28 TAC §§133.307, 133.308, 144.1–144.7 and 144.9–144.16 Regarding MDR of Fee Disputes, MDR by Independent Review Organizations, and Arbitration.
 
 
According to a release, the amendments relate to medical dispute resolution (MDR) activities conducted by the TDI-DWC. “The purpose of these amendments is to conform the rules to various statutory amendments that concern medical fee dispute resolution and the resolution of disputes of independent review organization (IRO) decisions by the TDI-DWC. Specifically, these proposed amendments are necessary to clarify existing rules and implement and enforce statutory provisions of House Bill (HB) 2605 and Senate Bill 809, enacted by the 82nd Legislature, Regular Session, that impact the appeal of medical fee dispute resolution cases and decisions issued by IROs,” it says. [WCx]
 
 
The proposals will publish in the March 23, 2012, issue of the Texas Register and may be viewed on the Secretary of State website at http://www.sos.state.tx.us/texreg/index.shtml once published. A courtesy copy of the proposals is currently available on the TDI website at http://www.tdi.texas.gov/wc/rules/proposedrules/index.html.
 
Note: If your company has any developments you'd like to share, please send them up us at: RShafer@ReduceYourWorkersComp.com

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR:  
www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

How Nurse Triage and Nurse Case Management Work Together to Reduce Workers Compensation Costs

Employers are continually searching for ways to reduce workers compensation costs. Triage, where a nurse immediately assesses the employee's medical condition and in some cases arranges for the medical care, is growing rapidly as one of the most effective ways employers can control workers comp cost. In triage, the nurse is involved at the very beginning of the claim. The triage nurse evaluates what medical care is needed through a phone call with the injured employee at the time of injury, provides a list of approved in-network doctors or medical clinics, then passes the claim to a nurse case manager who follows through with the medical provider, the employee, and the employer to ensure the needs of each are met. Companies using nurse triage consistently have very high "penetration rates" meaning that a very high percentage of employees utilize in-network providers; penetration rates for companies using nurse triage are frequently higher than 90%, many approaching 100%.
 

 
Triage in workers compensation is a concept that has been borrowed from hospital emergency rooms where the triage nurse is responsible for immediate assessment of the individual's injury and organizing the treatment based on the seriousness of the injury. In workers compensation, the triage nurse immediately evaluates the nature and type of the employee’s injury and directs the employee to the proper level of medical care whether it is first-aid, a walk-in clinic, or an urgent care facility. Sometimes the employee is given home-care instructions. (WCxKit)
 
 
The proper use of triage eliminates lag time and indecision. The injured employee, the employee’s supervisor or a co-worker (in an emergency situation) can report the occurrence of the injury to the triage nurse by phone. Most triage organizations provide a toll-free “hot-line” number for workers compensation claims to be reported and are staffed 24/7. The triage nurses that answer the calls are trained to obtain all necessary information in order to perform a comprehensive evaluation of the medical needs of the injured employee. The triage nurse will use treatment protocols and algorithms to identify the proper course of treatment. The employee is then directed to the nearest appropriate level medical facility. These nurses are specially trained and have had a minimum of 10 years of clinical experience.
 
 

The triage nurse does not stop after directing the employee to the medical facility. The triage nurse can then contact the medical facility to inform them the patient will arrive soon. Or, this can be done by the employer's workers compensation coordinator. The triage nurse provides the medical facility with the information on the employee’s injury along with the employee’s name, address, phone number, date of birth, social security number, employer's name, address, phone number, and contact information. The triage nurse will also provide the medical provider with billing information and adjuster contact information. Reports of daily activity is sent to the carrier/TPA and the employer, if requested.

Nurse triage makes sure the employee gets to the correct LEVEL of care, but the nurse case manager takes over to "manage" care. Note: When triage is too closely integrated into managing care, it looses focus on preventing unnecessary claims and guiding injuries to the right level of care. 

 
Note: The triage system is more likely to refer more often when the triage provider gains economically from opening a claim. Even "features" that seem convenient like 800 numbers and aps that  make it easy for employees to find networks clinics themselves result in employees bypassing triage and going straight to the clinics.  

 
After the employee has had time to be treated, the case managment nurse will contact the medical facility the same day and determine the nature of the medical treatment. Sometimes, this can be done by a senior nurse reviewer or the employer's medical director. A senior nurse reviewer is a nurse who reviews and follows ALL claims from beginning to end; they monitor all claims within an insureds book of claims. A nurse case manager will inquire to see if there are any prescriptions that need to be filled, if there is any diagnostic testing (MRI, CT scan, EMG, etc.) that needs to be done, and if there is a need for durable medical equipment. The case management nurse will then advise the workers compensation adjuster of the prescriptions, diagnostic testing, and durable medical equipment that is needed. Once the adjuster approves the requested prescriptions, testing or equipment, the case management nurse will assist in arranging for it.
 
 
The case management nurse will also ask the medical facility for the return-to-work restrictions placed on the employee by the medical provider. If the employee can return to work with restrictions, the case management nurse obtains all the information on the work restrictions and contacts the employer to see if the employer can accommodate the return-to-work restrictions. IF the employer has a return to work coordinator, the return to work coordinator can make contacts related to transitional duty capabilities.
 
 
The recommendations of the medical facility for future medical care and the date the employee will be returning to the medical provider will be obtained by the case management nurse. If the employee needs diagnostic testing prior to the return appointment being scheduled, the case management nurse can follow up with the medical facility providing the diagnostic testing and provide the test results to the medical provider. 
 
 
The case management nurse (NCM) will facilitate and expedite the communication between the medical provider, the employer, and the workers comp adjuster. NCM also has the responsibility of keeping everyone informed about the medical status of the employee. The NCM will be in regular contact with the employee, the employer, the medical provider(s), and the workers comp adjuster. All information about the medical treatment, medical progress and return-to-work options are shared with all parties.
 
 
The length of time the triage nurse will continue to work on the new workers claim is determined by the arrangement between the employer and the triage company but generally the triage nurse will hand the case to the case management nurse once the initial care is evaluated. The case management nurse will normally continue on the case until the employee returns to work full time however there may be a need for a nurse case manager depending on the severity of the injury or the employee's inability to return to work even in a modified duty capacity. (WCxKit)
 
 
Integrating the triage nurse into the initial medical treatment allows the employer or insurer to set the tone and level of medical care and ensure the employee gets the appropriate level of care immediately. Then the nurse case manager helps to coordinate employee's return to work before the employee has the opportunity to adjust to the idea of not working. By providing medical management at the beginning of the workers comp claim, the triage process improves the return-to-work program results, reduces days lost from work, lowers the cost of indemnity payments, and lowers the cost of medical care. Normally, nurse triage can reduce the number of lost time claims by up to 40%. 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 

NEW 2012 WORKERS COMP BOOK:  www.WCManual.com
 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Five Benefits of Medical Expertise At Time of Initial Injury

 

pic6Nurse triage is the process of having an experienced nurse evaluate an employee’s medical needs and direct medical care by determining the appropriate level needed. Employers who do not have their own on-site medical clinic are turning to nurse triage as a means of controlling and impacting workers compensation cost.

 

 

Nurse triage companies operate a call center where experienced, trained nurses are available on a 24/7/365 basis. Also, employers who do not staff their on-site medical clinic during all shifts are using nurse triage to cover their employee’s medical needs when their clinic is not open. (WCxKit)

 

 

When an employee is injured on the job, the employee and/or supervisor reports the accident direct to the nurse triage company where a trained nurse talks with the employee. The nurse, using proven interviewing techniques, listens carefully to the employee’s description of the accident. He or she asks detailed questions and focuses on the employee’s medical needs. By using treatment protocols and sophisticated medical software, the triage nurse is able to provide an injury assessment. Based on the triage nurse’s assessment of the severity of the injury, the most appropriate level of care and the proper course of treatment can be determined. Then, a decision is made as to where the employee should be sent for medical care.

 

 

If the medical care cannot be provided by the employer’s on-site medical clinic or by administering first aid on-site, the triage nurse refers the employee to a preferred medical provider in their network (set up in advance) best suited to provide the medical care needed. By directing the employee to the most appropriate level of medical care, optimum medical care is provided sooner. This also eliminates expensive emergency room visits and prevents the employee from starting medical treatment with a medical provider only to be transferred to a different medical provider later.

 

 

1- A key benefit of using nurse triage is the transfer of making initial medical decisions from the employee’s supervisor to a trained medical professional. The employee’s supervisor may discourage the employee from having the needed medical care, as the supervisor wants the employee at work, or the supervisor will send the employee to a medical provider not best suited to treat the employee’s injury. Triage nurses are experienced RNs with recent clinical experience who are specially trained to do this job, and the training centers are impressive. I have toured Medcor’s training facility which is state of the art.

 

 

2- The nurse triage will notify the medical provider of the employee’s injury and advise the medical provider to expect the employee’s arrival. This is immediately followed by the claim being reported to all appropriate entities including the risk management department, safety, human resources and the work comp claims office. By addressing the injury immediately with the employee, the employer and insurer have the greatest chance of influencing the cost and overall outcome of the claim. If arrangements have been made with the nurse triage company, they can gather all the information needed and file the first report of injury with the claims office and the appropriate state government entity.

 

 

3- Nurse triage can also assist with early return-to-work programs by obtaining an employee’s job description and providing the job description to the medical provider. When the medical provider indicates light duty restrictions instead of returning to work full duty, the triage nurse will contact the employer with the details of the light duty restrictions. A timely determination is made on the employer being able to accommodate the restrictions and place the employee back on the job.

 

 

4- A triage nurse’s immediate involvement in a workers compensation claim shows all employees their physical well being is important to the company. The leads to a higher level of morale and trust in the employer. It also provides a big benefit for the employer – bottom line savings on the cost of their workers compensation – as the benefits of nurse triage greatly outweighs the cost for the employer. The nurse triage company can provide your company a cost benefit analysis that will show you the savings generated from using a nurse triage company.(WCxKit)

 

 

5- Nurse triage provides a way for the employer to be proactive in the management of workers compensation claims while at the same time being compassionate to the employee’s injury and needs. During a recent assessment of 20 locations of a trucking company using nurse triage, we found that the immediate conversation with the nurses turned many potential lost time claims into either med only claims or “self-care” claims where the employee could ice the injury, for example, and remain at work with his or her ankle inclined.

 

To learn more about nurse triage and other services, please find sources in our Directory.


Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

 

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

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WC GROUP:   www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Nursing Survey: Transformational Leadership, Workplace Injury, Absenteeism

 

pic4A national nursing assistant survey yielded some interesting findings as seen on the Health Care Management Review website. Brought to our attention by Jennifer Christian, M.D., the study tells that nursing assistants (NAs) are an important human resource in health care. They provide direct care to more than 1.5 million nursing home patients in about 16,100 nursing home settings according to the Centers for Disease Control and Prevention. A higher turnover rate in the field (about 66 percent in 2007) among NAs may be linked to reduced quality of patient care in nursing homes, according to the study.

 

 

Naturally, workplace injury is a serious concern among NAs, the study states. Transformational leadership (TL) has long been popular among management scholars and health services researchers, but no research studies have empirically tested the association of TL with workplace injuries and absenteeism among nursing assistants (NAs).(WCxKit)

 

 

The cross-sectional study explores whether TL is associated with workplace injuries and absenteeism among NAs. They analyzed the 2004 National Nursing Assistant Survey data. A multivariate logistic regression analysis was performed to test the role of TL in the context of workplace performances and results revealed the TL model was positively linked to workplace injury in the level of NAs. Injury-related absenteeism was also associated with the TL style, indicating that TL behaviors may help address workplace absence among NAs.

 

 

Findings suggest introducing TL practices may benefit NAs in improving workplace performances.

 

 

Over the past 10-year period (1995-2004), about 800,000 nursing, psychiatric, and home health aides were injured in the workplace, the report says. Over the same period, 154 workers in the occupation were killed on the job. Nursing aides, orderlies, and attendants experience the third highest number of injuries and illness, exceeded only by truck drivers and laborers and material movers. (WCxKit)

 

 

In a prospective study investigating workplace injuries among NAs in Washington State, revealed that about 46 percent of the sampled respondents reported back and shoulder injuries. The study was based on a national survey and reports that more than half of certified NAs had at least one work-related injury in the past year. Prior studies have suggested that occupational injury may be blamed for the attrition rate of NAs.


Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

 

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:   www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Five Times to Use Nurse Case Management in Workers Comp Claims Management

In past articles, you have read about the wrong times to use Nurse Case Management (NCM) and other tools that adjusters have at their disposal. Remember, all of these services are not bad to use; in fact, I highly recommend them. They need to be utilized correctly for optimal impact on the file. Senior nurse reviewers are one type of nurse that can be used on ALL claims; the senior nurse reviewers manage the medical portion of the claim and are very effective.

 

 

Five times to use NCM:

 

  1. Use a NCM to get a doctor to elaborate more about what is going on
    Just becauseyou assign a NCM to your file does not mean the NCM has to be on the file forever. Make sure there is a planned time to end the engagement. Use the NCM for a couple of doctor appointments when you cannot figure out what the doctor is looking for. If someone has a strain-type injury and it has been six to eight weeks, andan Independent Medical Evaluation (IME) supports ongoing disability for whatever reason and it relates back to the workers comp injury, then it is time to ask the treating physician questions.

 

Find out what is being diagnosed, what the exact treatment plan is, what the backup plan is, if the doctor is thinking about referring to an orthopedic surgeon for an evaluation, etc. All of those reasons  show the treating doctor  you are not going to stand idly by while the patient comes back every 30 days after numerous failed attempts at conservative treatment. This shows you are being proactive on the file. You want to know what is going on so the file can be handled, forecasted, an appropriately reserved. For employers who stay on top of things, their Work Ability Form will contain this information and it will be obtained on the very first medical visit.

 

 

  1. Use NCM if you have a compensable claim in a geographic area you are not totally familiar with, with physicians you have not heard of
    This is another examplewhere one can use a NCM for a short period of time. It can be helpful to ask an NCM for assistance, when there is a claim in an unfamiliar area of your state or in a different state than you usually handle. Most often these nurses know the geographic area, or know someone in the area, and they can help you in getting some background on the doctor, what treatment plans are recommended, and how successful the doctor is at compensation claims in general.

 

 

Some surgeons are “known cutters,” meaning if a person comes to them for an evaluation, they recommend surgery even when surgery may not be the only option for treatment. Knowledge provided by the NCM can help your and your claimant know issues specific to that office ahead of time, before receiving a surprising report.

 

 

  1. Use NCM early on in complicated claims to gather medical and make the claimant feel at ease
    Nurses, whether telephonic or onsite, know just what to say to the other nurses to get medical records quickly. This is very helpful early on in a workers comp file when there is a serious injury. When the adjuster is trying to determine the extent of the injury or maybe what type of surgical procedure was performed, NCMs are known to work miracles in getting adjusters what they need. Even more important, the claimant automatically feels “taken care of” when talking to a nurse. This is especially true when speaking to the NCM before the adjuster speaks with her (or him.)

 

 

In claimant’s mind, talking to a nurse, knowing the nurse will answer any questions, takes a weight off a person’s mind when going through the early claim process. Adjusters must remember workers do not get hurt all the time, and some are scared and have no idea what the future holds. An injured  worker worries about bills, money, health, and returning to work. Discussing health issues with the NCM leads to psychological wellness and faster physical healing.

 

 

  1. Use NCM if there are two medical issues going on: one work-related, and one not
    An employee with a wristinjured in a workplace fall may discover in the emergency room that while the fractured bone is from the fall, a degenerative tendon tear and advanced arthritic changes including several large bone spurs, are NOT. Yet, these all need to be taken care of at the same time while repairing the workplace injury, according to doctor recommendations. Getting the doctor to differentiate between what is work related, and what is not can become an issue and varies by jurisdiction. Consulting the NCM as well as your adjuster/counsel for clarification can ease this distinction.

 

 

Regardless of the cause, the tears, spurs, and any other damage will be repaired via the surgery your employee may not have gone in for if it weren’t for the workplace injury. The hardest part about a case like this is knowing what to cover under workers comp, and what not to cover especially regarding ongoing disability and workers comp wage loss payments.

 

 

When would the claimant recover from the fracture if the other damage was not there? What is your company’s obligation for rehabilitating the employee when you cannot distinguish between the original injury and the on-going issues healing? A NCM can work with the doctor’s office on trying to clarify this. You do not want to pay wage loss or ongoing medical benefits for something that is not your responsibility. An IME can also address this but it is worth asking a NCM first, which may prevent the costs of an IME.

 

 

  1. Use the MD Guidelines in conjunction with NCM
    Every insurance officeshould have at least one copy of the MD Guidelines. This guidelines are updated frequently, and elaborate on nearly every occupational claim diagnosis. They provide the time frame from injury to full duty depending on employee age, job classification, gender, and zipcode. It should be used as a template for the lifespan of a claim. Once a claimant nears the time for full duty, if they are physically not ready, the adjuster needs to step in. There is likely something else going on and it is a red flag for the claim. At this time, a physician could review the medical situation. (WCxKit)

 

 

Finally, NCM and MD Guidelines are useful tools an adjuster has to help with claims, and when properly utilized they can be a crucial asset to handling a claim. As long as they are being used effectively, they should be utilized as often as they are needed.

NOTE: The Utilization Review Accreditation Commission (URAC) is an umbrella organization responsible for certifying Nurse Case Managers (NCM); Triage Nurses (TN); Telephonic Case Management (TCM); Field Case Management (FCM); Utilization Management/Utilization Review (UM/UR); and Peer-to-Peer Review. To maintain quality control use vendors which are URAC certified. URAC has stringent protocols for education, credentials, and training for these services.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 


Our WC Manual: 
http://corner.advisen.com/partners_wctoolkit_book.html

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

4 Types of Workers Comp Claim Leakage You Have Not Heard Of Yet

 
Errors in payments, usually referred to as "leakage," are a major issue for any insurance company involved in workers compensation claims. Generally “leakage” is classified into two types: hard and soft.
 
 
Hard leakage refers to erroneous payments made on claims without coverage, e.g., a claim is paid when no policy coverage or compensability exists.
 
 
Soft Leakage refers to overpayments to claimants in wage compensation, errors in medical payments, and errors in payments to medical providers after a claim is denied or disputed.
 
 
There is an area not often mentioned, however: vendor leakage.
 
 
Vendor leakage involves payments to various outside vendors used in investigation and claims handling such as nurse case management, surveillance, independent medical evaluation (IME) companies, and vocational assessments. (WCxKit)
 
 
1. Nurse Case Management Leakage
Many companies use outside vendors for nurse case management (NCM). Adjusters use these nurses to assist in gathering medical records, to talk over medical issues with physicians either onsite or telephonically, and to meet with claimants to get another view of the ongoing medical complaints a claimant may have.
 
 
Leakage can occur when NCM is used on claims where it is not necessary. Too often adjusters have a high claim volume and, to save time, they assign an outside NCM to assist on uncomplicated medical claims. This is not only expensive, but also not needed.
 
 
For example, if a claimant has a typical back strain with no internal structural damage and no pending surgery, there is no need to involve a NCM. But in order to keep an eye on the claimant’s medical treatment, an adjuster assigns a NCM to oversee the medical portion of the file.
 
 
Adjusters are known to assign NCM from time to time solely to gather medical records so they do not have to call the provider and request records. This is both a waste of claim expense and a sign of a lazy adjuster.
 
 
NCM should only be used when there is a complicated surgical case, when congenital medical issues could complicate healing after injury (e.g., a case with a claimant with severe diabetes or morbid obesity), or in scenarios when the same claimant has a number of similar complaints/injuries throughout years in the workforce, indicating the presence of a repetitive injury that could lead to a severe injury if the work duties are not corrected. Any other use of outside NCM is a waste of claims dollars and a waste of the nurse’s time and effort.
 
 
2. Surveillance Leakage
First of all, surveillance does have its place in certain claims and secondly, not all surveillance is a waste of time. However, in most cases surveillance does not greatly impact the outcome of the claim. Depending on the jurisdiction, videotape of a claimant walking around outside or running various mundane simple errands will not impact the compensability of the claim. A workers compensation claim does not disable someone from performing most general activities of daily living.

Keep in mind though that even though it does not influence the outcome of the claim, it may be very useful to build internal management commitment for your program or be a deterrent to fraud when others in the facility become aware that extent of injuries is verified via surveillance. In fact, we at  Workers Comp Resource Center are huge proponents of using surveillance to verify the extent of any injury before a settlement is offered. When one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorizing payment of a settlement. LowerWC.com is a stickler for detail.

 
 
Surveillance is typically costly, and unless an employers has an inside tip that the claimant has other employment, or is routinely breaking medical restrictions, it may not be useful. Surveillance without a purpose is considered leakage.
 
 
3. IME Leakage
Independent medical examinations (IME) are probably the most commonly used tool for adjusters. IMEs are used to make a medical correlation between the objective injuries a claimant may have, and how they relate back to the workplace injury. Inexperienced adjusters will send a claimant for an IME too soon, or too often. The results will shoot their defense of the claim in the foot because, depending on the scenario, the IME physician does not have a reason to terminate ongoing medical benefits. A typical strain can last up to eight weeks, and if the company does an IME at three weeks, the claimant is still in the healing stages and the company will either have to wait for the treating doctor to release the patient from care or perform another IME later and incur extra expenses. So, untimely IMEs are leakage. Using an M.D. to review timing of an IME can eliminate this type of leakage.
 
 
Depending on the jurisdiction, an IME may cost anywhere from $575 and $3,000, which often does not include medical record review, adding hundreds of dollars to the total bill. Plus, costs can vary on the specialty of the physician and the location of the IME. In our experience, which includes many claim audits by an M.D.,  about one-third of IMEs are unnecessary.
 
 
Often the treating physician can address any concerns an adjuster has regarding injury causation, and correlation of symptoms to the injury. This is usually free, and it only takes the time of the adjuster to draft a good letter to the treating doctor outlining the concerns. If the treating doctor will not respond, or it appears a claimant is over-treating for the injury, then an IME is warranted.
 
 
IME physician reputations are sometimes a greater factor than their actual report. There is a physician in Wisconsin who writes a good IME report, but when judges see his name, they disregard his opinions. Plaintiff attorneys and administrative law judges often see the same IME physicians again and again, and if these physicians have given poor depositions in the past or write overly-aggressive reports failing to support objective medical diagnoses, the IME report is not worth the paper it is printed on.
 
 
An IME is a fantastic tool when used properly, with the appropriate physician, with a cover letter written by an M.D. requesting specific medical information, at the correct time it is needed. Any overuse or improper use just leads to more expense sunk into the claim for no strategic benefit.
 
 
4. Vocational Assessment Leakage
When a claimant can no longer perform their pre-injury job, adjusters sometimes bring in a vocational expert to comb the job market for potential work based on the claimant’s experience and medical restrictions.
 
 
Similar to IME reports, the reputation of the vocational counselor is very important. In most litigated cases, a voc expert is used to show the injury and subsequent permanent medical restrictions the worker has doesn’t deter him or her from any future employment. But, this argument must be made correctly. Plenty of outside factors are taken into account, including geographical location, the current job market, the claimant’s transferable skills, and the overall chance that the injured worker will have gainful, long-term, satisfying employment within these restrictions. You usually can’t take a man who was a welder his whole life and turn him into a greeter at a grocery store, and expect a judge to be satisfied with that. This can be avoided by selecting a vendor that searches for jobs in the open market, sets up interviews, and follows up after the interview to make sure the employee attended the interview appropriately dressed, for example — making a real effort to get hired.
 
 
Adjusters know when a claimant sustains an injury resulting in the injured worker having permanent medical restrictions, the claim can go down several routes. First, the adjuster should go to the employer where the claimant was injured to try to either create a job within the restrictions and pay range, or to attempt to modify the worker’s position to accommodate medical restrictions. If this can be achieved a voc expert is not needed. Otherwise, vendor’s fees are spent on countless hours looking for jobs outside of the employer's facility.
 
 
In summary, leakage affects all insurance companies, third-party administrators (TPAs), self-insured employers, etc. Unnecessary outside vendor usage contributes to excessive claim costs and is known to be used more often than needed in day-to-day claims' practices. (WCxKit)
 
 

Consider on a larger scale the costs going into a basic, lost time claim. It is a good bet some of these costs can be eliminated with a more proactive adjuster who is open to getting the injured worker back to the employer by strengthening the adjuster/employer/worker relationship. Knowing your vendors, selecting your own vendors or becoming VERY WELL acquainted with TPA vendors, and specifying the triggers for use in your account instructions, can go a long way toward making your program more efficient.


Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

How to Use Nurse Case Management to Lower Federal (FECA) Workers Compensation Costs

Taming Federal Workers Compensation (FECA) with Medical Expertise
I had an interest in learning more about how Federal workers compensation cost controls operate, so I asked Lisa Firestone, owner of Medical Care Advisors (MCA), what type of cost containment can be done on the federal side of workers compensation. Here’s what she told me.
 
 
After spending years in the alphabet soup of federal contracting, Managed Care Advisors (MCA) has thrown its hat in the ring of acronyms-as-words with  CARE: Concentrated Action for Recovery and Employment. They take a special approach to nurse case management.
 
 
One of the tools utilizing the skills of the multi-team approach in the federal sector includes the CARE team meeting face-to-face with the relevant representatives of the Department of Labor’s Office of Workers’ Compensation Programs (OWCP). In the federal sector, the OWCP is responsible for the official adjudication of claims. This contact drives case progression in three deliberate phases:
 
1.     Before – Case summaries are submitted to the assigned OWCP Claims Examiners prior to a meeting. While offered as a form of preparation, this step sometimes prompts action and resolution for cases even before the CARE team arrives.
2.     During – The meeting itself provides a platform for clear communication, and brainstorming for case resolution. Simply put – no one has to play phone tag. What might have taken months to happen before can now be decided in minutes.
3.     After – Most importantly, these meetings help establish rapport between a Federal Agency client and an OWCP Claims Examiner and other members of the claims staff up to the level of the District Director. When a Claims Examiner has a to-do list a mile long, being able to put a face with a name can be the difference between getting squeezed in today and waiting three weeks for a reply.
 
"The CARE unit of nurse case managers focuses on resolving our clients' long term cases," says Firestone,  including those on the federal workers’ compensation periodic roll. While management of older cases has always been an integral aspect of MCA's approach to case management, CARE is another step along the evolution of that commitment, she explains. The CARE team brings industry best practices to bear on these challenging cases.
 
 
I asked her "What do you do with a case of 1-30 years?" and she explained that while every case is different, a CARE nurse often begins with a methodical review of case records ranging from one to 30 years of treatment and administration, with emphasis on identification of obstacles to resolution. This information is often distilled into a one-page summary, which can immediately bring any stakeholder in the case up to speed. The CARE team then works with the client to formulate a resolution strategy. While plans are a good starting point, the CARE unit's real strength is finding creative ways to jump-start these stalled cases, and following through on identified plans and actions.
 
 
Since many of these cases involve ongoing lost time days, MCA’s approach to case management stresses objective verification of total disability, analysis of medical care utilization, empowerment of the injured worker, and clarification with employer and claims team that appropriate benefits are being provided and administered. The result of this team approach is reliable cost control. CARE nurses maintain the integrity of the injured worker and treating provider’s roles while analyzing objective data.
 
 
CARE nurses are able to progress these cases by using a variety of techniques. Telephonic contact with the injured worker ensures commitment to the healing process, and fosters a positive mindset for increased activity, including returning to work. Case reviews by the MCA Medical Director, an MD, identify gaps in medical reasoning, and avenues for case progression. Written contact with the treating provider opens communication and can lead to appropriate reductions of restrictions.
 
 
Lisa Firestone is an owner of Managed Care Advisors, Inc. (MCA) is an innovative, woman-owned small business enterprise specializing in managed care, employee health benefits and workers compensation consulting and case management services. Contact http://www.managedcareadvisors.com/

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com
 
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Workers Compensation Medical Management Techniques

Medical management in workers compensation is the use of claim handling techniques to control the employees medical care and the associated cost for medical treatment and disability. Normally a nurse case manager (NCM) is employed to coordinate the medical treatment of the employee. Medical management also includes the review of medical care to determine the medical necessity of the treatment and the causal relationship of the treatment to the injury being claimed.

 

Medical management has become a major part of workers compensation claims because the attending physicians feel more comfortable working with a nurse than they do with a work comp adjuster.   The adjuster may not be schooled in traumatic injury where as almost all nurse case managers have actively practiced as RN’s for at least 3 years. Therefore, the adjuster may lack the ability to converse with a doctor in an intelligent manner. The adjuster may also fail to recognize the underlying pathologies that could impact the claim adversely. However, turning the medical management over to a NCM does not relieve the adjuster of the responsibility for medical monitoring of the claim. The NCM and the adjuster should operate as a team. The NCM should always be in contact with the employer and the adjuster after each doctors visit or contact with employee. (WCxKit)

 

When the NCM is an employee of the insurer or the third party administrator handling the claim, the NCM can enter his/her activity notes directly into the adjusters claim file. When the NCM is a separate vendor, the NCM should be granted limited access to the adjusters files note for the purpose of documenting the medical management activities as they occur.

 

The NCM generally consults with the treating physician during the medical treatment period and will attend the medical appointments with the employee. This will give the NCM insight into the employee that the adjuster may never be aware of otherwise.

 

The NCM should be employed as soon as the claim appears to warrant it. Depending upon the severity of the injury, the NCM may be needed immediately, or they may not be required until the employees medical recovery is unusually long. Also, a NCM maybe employed when some underlying medical issues occur or medical care not related to the injury begins to appear in the claim.

 

The goal of medical management is to return the employee to gainful employment through appropriate treatment in a timely manner. This will minimize the lost time and disability. The NCM will be instrumental in arranging transitional duty jobs suitable for the disability during the recovery process.

 

It is imperative that the NCM have a full job description, and in some situations, actually see the job in operation. This will give the NCM the ability to properly discuss the case with the treating physician. If necessary, the NCM should obtain a video of the employees job operation and provide it to the treating physician. It will assist the NCM in obtaining the treating physicians consent for the employee to return to his old job. If modifications or changes in the employees job are needed for the employee to be able to do his job, the NCM will work with the employer to accommodate the employees limitations.

 

The work comp adjuster also has a role in medical management. The adjuster should verify the employee is not working and can not work due to the medical disability. Before issuing payment of temporary total disability benefits, the adjuster should verify the employee is pursuing curative treatment. The adjuster can do this with direct contact with the employer, the employee, the NCM and the treating physician.

 

A mistake often made by the adjuster is to place the claim on automatic payment of disability benefits without maintaining regular contact with the employer, employee and NCM. The adjuster should always be knowledgeable of the employees medical condition and the level of activity the treating physician will allow the employee. Without the adjuster involvement, if the claim is on automatic payment of disability benefits, overpayment of benefits will likely occur. If the employee does not later have a claim for permanent disability benefits, the overpayment of temporary disability benefits will be difficult to recover.

 

In approximately half of the jurisdictions, the employee is given the option of selecting his own attending physician. Often this is not a problem. However, some plaintiff attorney friendly physicians may have a tendency to extend the disability period more than normal. Or, they may begin to treat non-injury related medical problems of the employee. In these situations, it is essential for a NCM to be assigned to the claim.

 

If the injury is severe or if the recovery time is longer than normal, an independent medical examination (IME) should be considered. The doctor who will perform the IME should be provided a complete copy of the medical records and a full description of the employees job. The IME doctor should never have to rely on the employee for information about the job. The results of the IME will provide the NCM and the adjuster with valuable information for claim management and disposition.

 

As some jurisdictions impose time limits on when the IME can be performed and imposed restrictions on the number of IMEs that can be completed, the NCM in conjunction with the adjuster should determine the most opportune time for the IME.

 

A separate area of medical management is the reviewing of the physician’s bills for proper charges and the need for the care provided. Almost all companies reviewing medical bills for accuracy are now using computers to do the bill reviews. In the states where usual and customary fees are used, the medical bill review will compare the fee schedule to the provider’s bill in order to determine the appropriateness of the billed fees.

 

A NCM through medical management can bring about a reduction in the amount of time the employee is disabled and have an impact on the medical treatment cost. However, the adjuster needs to be vigilant in managing the NCM. Normally, the NCM is billing an hourly fee plus expenses. The adjuster needs to reviews the billing and the medical status of the employee to verify there is an on-going need for the NCM services. At such point the cost of the NCM begins to equal the savings on the claim, the NCM should be released from further responsibility on the claim. (WCxKit)

 

Medical management when properly used will lower the cost of the work comp claims.   The employer should verify the adjuster is using all medical management techniques noted above.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
Contact:  RShafer@ReduceYourWorkersComp.com or 860-553-6604.
 

WC IQ TEST:  http://www.workerscompkit.com/intro/

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

 

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact 
Info@ReduceYourWorkersComp.com

 

Anatomy of an Employer Dispute with Their Third-Party Administrator

Success Story:  A large transportation company thought their claims were not handled aggressively enough and poorly performing adjusters were driving workers up comp costs. The dissatisfaction had grown to such proportions that they put the business out to bid. They did, in fact, change TPAs.

 


Resolution: 
 One MD and one senior claim analyst reviewed 20 claims in each of three offices (TX, CA and MA) and found there was a problem with the MA office. The adjuster handling their claims in that office was inexperienced and disorganized. There were administrative quality issues such as lack of supervisor oversight, insufficient investigation, untimely 3-point contact, no recorded statements being taken, and claimants were being overpaid because the “average weekly wage” was miscalculated. IME’s were overused and medical causality was not established prior to claim payment. Pre-existing conditions were not recognized by the adjusters or nurses resulting in higher than necessary reserves. Nurse case management was being brought in too late to be effective. The client, however, thought the NCM was “too expensive” but the problem was really that it needed to be brought in earlier.

 


We set up
 new triggers so when an employee does not return to work within 2 days a nurse case manager is immediately assigned. The TPA enhanced their training program to ensure nurses were reviewing files for pre-existing conditions and completeness of medical records. The employer retained a part-time medical director to review claims if an employee had not returned to work within two weeks. IME’s were not requested until the medical director reviewed the file, insured complete medical records were obtained and crafted a custom letter requesting specific medical information.

 


The employer
 had insufficient staff to monitor or manage the TPA; there were 3,000 claims annually at over 500 locations with only one person, who was not an actual risk manager, assigned to workers compensation. We suggested the company hire a risk manager and select eleven people (one for each region) to serve as WC Managers (WCM) which was quickly done. Onsite training was done for the new WCMs. The TPA participated in the training to meet the WCMs then did a “national rollout” providing new “panel cards” so employees could select network physicians. The TPA met with each location to open communication channels.

 


We met with
 the client, TPA and broker on weekly conference calls for the next 52 weeks until all suggestions had been implemented. To keep team members accountable, we sent an “Implementation Action Plan” to each participant following the conference call.

 


Result:
 Losses down 25% for past 3 years and continuing.
Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

 

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

 

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: 
Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

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