A high percentage of self-insured employers and insurers make the mistake of allowing the adjuster to use his or her own discretion on when to use a nurse case manager on a claim. This can result in the medical cost and medical treatment getting out of control because the nurse case manager is not brought into the claim timely. Studies by Broadspire and other medical management companies have shown the return on investment of a nurse case manager to be anywhere from 3 to 1 to 20 to 1.
Specific Guidelines Should Be Established
Instead of allowing the adjuster discretion on when to utilize a nurse case manager (the adjuster is normally late in making the decision to use a nurse case manager), it is better to set specific guidelines on which claim files should have a nurse case manager assigned.
There are two types of nurse case managers. The nurse case manager who works from an office and handles all of the work by telephone, email, fax and regular mail is normally referred to as a telephonic case manager or TCM. The nurse case manager who works in the field, meeting in person with the injured employee and the medical provider(s) is referred to as a field case manager or FCM.
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Criteria To Trigger Use of Nurse Case Manager
Common criteria used to designate or trigger the use of a nurse case manager includes:
- Immediate hospitalization after an accident
- Amputations of fingers or toe
- Second degree burns over a limited skin area
- Electrocution
- Concussions
- Vision impairment
- Immediate loss of hearing
- Heart attack on the job (if the claim is compensable)
- Stroke on the job (if the claim is compensable)
- Rotator cuff or other shoulder injuries
- Meniscus or other knee injuries
- Ankle sprains
- Back injury claims
- Neck injury claims
- Joint dislocation
- Carpal tunnel syndrome
- Tendonitis
- Fractures that require time off work
- Hernias
- Asbestosis, pneumoconiosis and other occupational lung diseases
- Occupational skin diseases caused by chemical exposure
Criteria To Use a Field Case Manager
While either a Nurse Case Manager or a Field Case Manager can provide case management services on the above types of claims, there are some situations where it is better to have a Field Case Manager involved in the case management. This includes:
- Attendance at independent medical examinations
- Attendance at doctor appointments
- When the employee has been referred by the initial medical provider to a specialist
- Brain and brain stem injuries
- Catastrophic injuries
- Spinal cord damaged or severed
- Amputation of hand, arm, foot, leg
- Third degree burns or burns over 25% or more of the body
- Total loss of vision
- Multiple amputations
- Multiple traumas from the accident
- Narcotic addictions
- Employee’s failure to improve medically during the course of treatment
- Suspected improper course of treatment of inadequate treatment
- Employee non-compliant with doctor’s instructions
- Employee missing medical appointments
Benefit of Medical Case Management Is Well Established
As the benefit of medical case management is well established, some self-insured employers and insurers are taking the decision on whether or not to use a nurse case manager out of the adjuster’s hands, and mandating when medical case management will be used. When the insurer or self-insured employer takes this approach, they will either assign a nurse case manager to all indemnity claims, or have the medical case management company review all reported workers’ compensation claims and select those where the Telephonic Case Manger or the Field Case Manger can make a difference.
We recommend medical case management on any claim where the injured employee meets any of the medical treatment guidelines outlined above. For assistance with when to use a nurse case manager, or when to decide between using a Telephonic Case Manger or a Field Case Manger, please contact us.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and 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. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
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