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.
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.
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: [email protected] or 860-553-6604.
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