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 an NCM to get a doctor to elaborate more about what is going on

Just because you assign an 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, and an 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.

2. 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 example where one can use an 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. The 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.

3. 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.

4. Use NCM if there are two medical issues going on: one work-related, and one not

An employee with a wrist injured 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.

5. Use the MD Guidelines in conjunction with NCM

Every insurance office should have at least one copy of the MD Guidelines. These 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.

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: [email protected].

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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.

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