Let’s face it: The few “ugly” claims are what really take up most of your time, resources, and expenses, as well as sending your modifiers through the roof.
Case management should not be needed for minor, medical-only, uncomplicated claims. If your injured worker stubbed a toe or had a paper cut and your adjuster can’t recognize what bills are appropriate for this, you need to look more closely at your carrier.
But, whether you are a huge employer with millions in annual costs or a small employer with one big claim every few years, you should know how to handle the “uglies” so they don’t handle you.
A great resource is the Nurse Case Manager. There are companies large and small who can provide this service. The carrier or TPA will also often have in-house nurses that they can utilize, though usually on a limited basis.
15 Points to Consider When to Assign a Nurse Case Manager to Your Claim
- Catastrophic injury – severe injuries involving at least one of the following: need for hospitalization, anticipated significant out of work time, multiple body parts injury, need for immediate or urgent surgery, injuries to the head or spinal column, or significant burns.
- HR issues – an injured worker who is on a “probation” program or slated for possible termination for violation of HR policies, who develops a “subjective only” injury (like back or neck pain), possibly to avoid termination
- Early attorney involvement – if your injured worker is receiving treatment right away and there are no obvious issues, but he or she obtains representation within a few days of reporting the injury, you may want to look closely at the claim
- Extended time out of work – after about two weeks, it is increasingly difficult for even good employees to get back into the “work” mindset. Injured workers need to remain motivated and focused on the goal of recovery and return to work.
- Noncompliance – an injured worker who is non-complaint with treatment recommendations, follow-up appointments, diagnostics etc., can benefit from nurse case management involvement to increase compliance.
- Over-utilization of pain medication – there is a time for opioid (narcotic) usage: mostly immediately post-injury or post-operative. An injured worker who increases their usage with time instead of decreasing may need assistance with medication management.
- Doctor choice – in a state where the employees choose their own provider, if the injured worker chooses a treater known to be “pro-plaintiff.”
- Doctor shopping – if your injured worker is changing treaters, he/she may be searching for either prolonged time out of work or continued opioids (narcotics).
- Near retirement age – wouldn’t a nice, fat settlement ease your injured worker straight into retirement? Let’s stay on top of that one!
- Asking about settlement, especially early in the claim – “My cousin/friend/dad etc. got hurt at work and got a pile of money — am I going to get money from my company too?”
- Differing medical opinions, recommendation for surgery – if you’re unclear on the best course of treatment, NCM can assist with review and clarification of medical documentation, recommendation for treatment or further diagnostics or evaluations
- IME – many IME (independent medical exam) companies will send a copy of a big stack of meds to the doctor along with a standard, fill-in-the-blank letter. If you’re just looking for MMI on a simple case, fine. For a complex case, a nurse can review the meds and summarize for the evaluator, highlighting the important information, and ask the important questions.
- Delay in reporting – late reporting of any claim (especially over one to two weeks) is a definite red flag that requires investigation of the claim’s validity
- History of injury to the same body part – if an injured worker has had a previous injury, treatment, or, especially, previous surgery to the same body part that is now injured, a detailed medical review of the old records should be performed.
- Employer needs assistancewith their transitional work program – a good nurse case manager can assist with a return-to-work program by reviewing the injured worker’s restrictions with the employer and discussing possible job modifications to accommodate work abilities. The nurse can also help to educate the employer on the importance of a transitional duty program, and can facilitate employee compliance with this program.
Now that you’ve decided you need a nurse case manager, you’re wondering about two more things: Money and Quality.
- Money: Is this Cost effective? Are you kidding? Sure you have to pay your nurse case managers. But think about this: you’re paying TTD, you’re paying medical treatment, you’re paying attorneys . . . big bucks, right? Case Management works with the injured worker and all other parties to GET THE CASE RESOLVED. That’s the goal. Nurse case managers put their effort towards maximizing recovery, in a timely and cost-effective manner. Generally, case management costs can be easily recovered by avoidance of unnecessary tests or procedures, a faster return to work, or a shorter medical treatment time.
- Quality:Talk to your nurse case manager. Remember, the in-house nurses working at the carrier’s office only work for the carrier. They generally will not attend an appointment with an injured worker, or develop a relationship with a doctor, or be a resource for an employer. Look for a nurse who is a personality match with all parties – employer, carrier/TPA, attorney etc., and look for someone you feel can work with your employees. You want someone you trust, and someone who understands the specific needs, goals and qualities of your organization.
An experienced, effective nurse case manager will be able to balance the injured worker’s requests for everything from handholding during an injection to inappropriate surgery, with the adjuster’s need for facts and quick claim resolution. It’s a win for everyone. The injured worker has an advocate who s/he appreciates, the employer has help with everything from planning a transitional work program to a treatment timeline for an injured worker, and the carrier/TPA and defense attorney have the assistance of a nurse case manager familiar with the state jurisdiction and laws, who can assist with facilitating an appropriate and cost-effective treatment plan and advise on future anticipated exposure, settlement costs, and address specific areas of concern.
So stop stressing over those “ugly” claims — find a good nurse case manager and make your claims a little nicer to look at!
We welcome as a new contributor:
Author: Kelly Haile, RN, CCM, WCCM is an experienced Nurse Case Manager who advocates working closely with each employer to refine their Workers’ Comp program to provide better post-injury care, excellent medical case management and timely communication. We provide services primarily in the PA, NJ, DE and MD areas. You can reach Kelly in her role as Director of Case Management at NursePartners, LLC, by phone at 610-323-9800, fax 610-323-8018, or email KellyHaileRN@verizon.net.
WC Roundtable LinkedIn: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
Return To Work Calculator: http://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.
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