Are most carriers taking advantage of using nurse case managers to help move claims along to facilitate closure?
I think it is safe to say some are, and some are not. Usually adjusters are told to use case management only on the severe high-exposure cases. These being major spine surgeries, multiple fracture injuries, and cases with multiple surgeries and different medical care needs to be implemented and coordinated.
But what about average surgical lost-time work comp cases? Carpal tunnel, a knee surgery, a bicep tear. Typically the adjuster is left to handles these claims themselves. They will use their diary system as their fallback so they can monitor what is going on medically with the claim.
But that is also the problem. If you have a lot of cases with the majority of them being cases involving lost time either surgical or not, then how are you being proactive in bringing the claimant back to work and back to full duty? Just monitoring the claim as it goes from doctor appointment to doctor appointment is not being very proactive. I understand that sometimes that’s what you have to do, but you have options.
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Nurse Case Manager Brings Communication and Medical Expertise to Doctor Appointments
When you have a high caseload, you cannot be everywhere at once. This is where the nurse case manager comes in handy. The nurse can be your eyes and ears at the doctor appointments. They update you the day of the appointment after it is completed. IF you are just waiting for medical records, it can take weeks. Plus, chances are the nurse will be talking to the claimant more than you are, and can tip you off to potential red flags to recovery long before you spot them in medical records.
A nurse case manager can also help you to prevent a file from slipping through the cracks. Even the best adjuster has missed a file every now and then. These misses can be very costly, especially when wage loss is concerned. A nurse will keep you up to date, and will be more reliable than using just your diary system.
They also have the time to work the case from a medical standpoint. They talk with the doctor, and can help in claims where a pre-existing condition is also present around the compensable work injury. The hardest issue in these cases is separating the 2 conditions, and the case manager can help the doctor focus on the work injury while brushing aside the non-occupational condition.
Nurse Case Manager Can Assist With Referrals, Reserves, Medical Plan of Action
Nurses can also help to provide DME equipment quicker, and coordinate any other vendor activity you need done. If you need an Independent Medical Opinion, the nurse may know the perfect doctor for your case. They can also copy the medical records, send them to the IME doctor, draft the cover letter, attend the appointment, and talk with the doctor afterwards to get questions answered. As an adjuster, it would take you a good chunk of time to do that yourself. Plus the nurse will update you right after the appointment instead of waiting days to get the actual IME report.
Reserving can also be assisted by a nurse on the file. The nurse may have a better handle on medical costs, barriers to recovery, prescription costs, and the outlook to a favorable Maximum Medical Improvement projection.
Carriers may have the mindset that an onsite nurse is not cost effective on normal lost time comp cases, but I think this is where they come in the most handy. By being there for the adjuster, it allows the adjuster to focus attention on the more troublesome cases.
Adjuster is More Efficient With Expertise of Nurse Case Manager
If you have an accepted claim with a surgery, why not let the nurse run with it and let the adjuster be updated by the nurse? It takes time to place medical records requests, coordinate doctor appointments, and come up with a medical plan of action. The nurse knows how to do all of this. For what they charge, it is cost effective since it frees the adjuster up to handle more important tasks.
Several adjusters that I know have a great network of nurses, and trust their opinions. But they only use them when a severe case comes around. Try using the nurse case manager on normal lost time cases. You will find out that not only is it cost-effective, but it makes the adjuster more efficient at moving cases on to closure. It is all about efficiency these days, and anything that can make an adjuster more efficient should be seen as a positive.
Author Michael B. Stack, CPA, Principal, 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: [email protected].
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