Using Medical Case Management to Control Work Comp Costs

When there are severe injuries one of the best ways to control workers’ compensation claim cost is through medical case management. While the role varies from insurer to insurer (or third party administrator), the primary focus of medical case management is the coordinating and planning of the medical care to expedite the return of the employee to work or to reach the employee’s maximum medical improvement.

Role of the Nurse Case Manager

The person providing the medical case management is the nurse case manager (NCM). The nurse case manager’s role in the workers’ compensation claim often includes

Facilitatingthe medical rehabilitation of the injured employee
In consultationwith the treating physician, evaluate the options for the best treatment plan for the injured employee
Coordinatingthe medical care to achieve the best possible medical results in a cost-effective manner
Insuring the proper utilization of medical treatment
Providingguidance to the adjuster about the medical care needed
Monitoringthe employee’s medical progress
Actingas a liaison between the physicians, the employee and the insurer
Facilitatingthe communications between the employee, employer and physicians
Keepingthe adjuster informed of the employee’s medical status and progress

10.Meeting with the employee and the employer to complete a detailed job evaluation

11.Assisting the employer in identifying the return to work options

12.Coordinating the employee’s return to work (either modified duty or full duty) with the employer, employee and physician

NCM Works for the Insurer

Regardless of whether you are in a state where the employee selects the treating physician or in a state where the employer selects the treating physician, the insurer selects the nurse case manager. Selecting the NCM allows the insurer the ability to monitor the medical care and to be knowledgeable of the on-going medical status of the employee. Since the insurer hires and pays the NCM, the NCM is considered an agent of the insurer.

Mandatory States

Medical case management is required by some state work comp laws and is optional or voluntary in other states. In the states mandating medical case management, the insurer (or employer if self-insured) provides medical case management as a medical benefit. It is considered a required benefit necessary to return the injured worker to productive employment. In the states where medical case management is mandatory, the employee does not have the right to refuse the involvement of the NCM.

Voluntary States

In the states where medical case management is optional, it is usually in the insurer’s best interest to provide medical case management. The proper utilization of the nurse case manger can eliminate delays in the employee’s return to work and positively impact the cost of the claim. If the employee declines the involvement of the NCM, the work comp adjuster should consider this a red flag development and seek out the reason the employee is reluctant to have medical case management.

It should be noted in the states where medical case management is not required by statute, the employee can accept the NCM’s involvement in the medical care but still limit the scope and extent of the NCM involvement. This is often true when the employee has retained an attorney to represent his/her interest. The attorney’s role is to maximize the recovery for the employee and can result in keeping the employee off work as long as possible. The professional NCM faced with this situation always strives to insure the employee receives the necessary medical care and is released to return to work as soon as medically capable.

NCM Training

Usually the medical case manager is a registered nurse; but in some states insurers and third party administrators use licensed practical nurses and/or nurse practitioners. In order to be effective as a medical case manager, the NCM must have an in-depth medical knowledge plus have relevant experience working in the medical rehabilitation field (knowledge of workers’ compensation is a plus)..

What the NCM Cannot Do

The NCM cannot deny the employee any medical care requested. If the NCM feels a line of medical care is unnecessary, the NCM can discuss with the physician why the physician is requesting the treatment in question. The NCM can provide recommendations to the adjuster about the necessity of requested medical care. If the adjuster agrees the medical treatment is not needed, it is the adjuster’s responsibility to deny the care. (workersxzcompxzkit)

Summary

Medical case management benefits the employee by insuring the best medical care and it benefits the employer by returning the employee to work more quickly. NCMs are trained medical professionals who provide a valuable service to the employee, employer, and insurer while reducing the overall cost of the severe work comp claim.

Author Rebecca Shafer, J.D. Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at: [email protected] or 860-553-6604.

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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.