Risk managers have come to realize that proper medical case management can have a major impact on the cost of workers compensation claims. Medical case management from the initial report of the work comp claim to the final conclusion of the claim will impact the overall outcome. An understanding of the various levels will ensure the proper utilization of medical case management.
Medical case management is often broken down into five primary areas (which occasionally overlap). The five areas of medical case management (also sometimes referred to as nurse case management) are:
- The triage nurse gets the claim at the time the injury is reported to the employer
- The senior nurse reviewer (SNR) gets the claim at the time it is reported to the insurer or third party administrators claims office
- The telephonic case manager (TCM) gets the claim from the adjuster when the claim triggers a predetermined parameter as specified in the account instructions, or in the judgment of the adjuster, is needed
- The field case manager (FCM) is assigned the claim when the adjuster determines the employee needs in-person medical assistance5. Complex Case Management is a specialty service where a team of health experts and claim experts move a long-term claim, often over 30 years, to closure.
- The medical director, a doctor, is involved in the complex medical cases or medical cases where causality is in question.
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The triage nurse will review the initial report of injury to determine the immediate medical needs of the employee. The triage nurse will direct the employee to the appropriate medical provider (in the states where the employer selects the medical provider) and arrange for immediate medical care in emergency situations. The triage nurse will evaluate whether or not the employee may need to see a specialist and whether or not the injury may cause the employee to lose time from work.
The initial directions provided to the employee and the triage nurses assessment of the severity of the claim is reported to the work comp adjuster. Many insurers and third party administrators will have the triage nurse follow up with the employee and the medical provider immediately following the initial treatment to determine the medical providers diagnosis and the need for further medical care.
The responsibilities of the senior nurse reviewer are to address the need for medical case management on the unusual or complex medical cases. For example, an airplane pilot flying long distances develops pulmonary emboli (a blood clot from the leg or another part of the body that gets stuck in the pulmonary artery leading to the lungs). The senior nurse reviewer needs to have extensive medical knowledge to assess whether the development of pulmonary emboli is due to the pilots many hours of sitting in the same seat or is due to a medical cause not related to the pilot’s occupation.
The TCM nurse is the busiest of the different levels of medical case management. Some employers and insures have a claims handling parameter that a TCM will be immediately involved in any case determined to be an indemnity benefits case. Other employers and insurers allow the adjuster to determine whether or not the TCM is needed. The nurse case managers role in the workers compensation claim will often include:
- Facilitating the medical rehabilitation of the injured employee
- In consultation with the treating physician……evaluate the options for the best treatment plan for the injured employee
- Coordinating the medical care to achieve the best possible medical results in a cost-effective manner
- Insuring the proper utilization of medical treatment
- Providing guidance to the adjuster about the medical care needed
- Monitoring the employees medical progress
- Acting as a liaison between the physicians, the employee and the insurer
- Facilitating the communications between the employee, employer and physicians
- Keeping the adjuster informed of the employees medical status and progress
- Meeting with the employee and the employer to complete a detailed job evaluation
- Assisting the employer in identifying the return to work options
- Coordinating the employees return to work (either modified duty or full duty) with the employer, employee and physician
The Field Case Manager(FCM) has a role similar to TCM with the principal difference being the “hands-on” approach of the FCM. The FCM will normally meet with the employee to discuss their injuries, especially if the employee has been hospitalized. The FCM will also accompany the employee to the various medical appointments. The FCM will normally be involved in the more serious injuries where rehabilitation will be needed or the nature of the injury is such that a permanent disability is expected. (WCxKit) Field Case Management Nurses can also assist with Life Care Planning, assisting with those issues that an injured employee with permanent disability might need to make their environment safer.
The most expensive claims can be almost life-long, long term claims, sometimes 30 years old. For some reason, these claims have been difficult to progress. This medical case managment service assists in removing obstacles the employee has had over a long period of time including medical problems, health challenges, and mental or psycho-social challenges. A team of health professionals work together to determine obstacles and develop a care plan to progress the case forward. These are the claims many risk managers and carriers simply give up on. Call me for a reference to this type of resources, or check in our Directory.
Important: nurse case managers and nurse triage nurses should be URAC Certified which has stringent protocol for education, credentials and training for these services.
The medical director is a doctor who has extensive knowledge and experience in the evaluation of medical conditions and the implementation of appropriate medical care. The medical director will act as a consultant and an adviser to the triage nurses, the senior nurse reviewer, the TCM nurses and the FCM nurses. The medical director can be called on to provide in depth medical reviews and to collaborate with the treating physician on the best course of medical care for the employee. Peer-to-peer doctors should be URAC certified; the best TPAs and carriers are URAC certified. This should be included in your RFP.
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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