6 Triggers for When, And When NOT to Use Nurse Case Managers

when to use nurse case managementNurse case managers are a hot topic in workers’ compensation, and with good reason. Used properly, they can generate great results for organizations in getting injured workers back to work as soon as possible and saving precious dollars for organizations. But there is often misunderstanding about how and when to use Nurse Case Managers. For example:


  • Should you use a Nurse Case Manager on every workers’ compensation claim?
    • No
  • If a Nurse Case Manager is used, should it be for the entire duration of the claims process?
    • No
  • Is there a difference in telephonic vs. field Nurse Case Managers?
    • Yes


Nurse Case Managers can reduce litigation rates, foster patient engagement in the recovery process, and provide vital communication among all stakeholders. They can also be a waste of money and add little value.


Understanding when and how to use Nurse Case Managers is key to getting the best bang for the buck.



What They Can Do


Research showing the potential value of Nurse Case Managers has resulted in some companies using them on every single claim from beginning to end. Many of these companies then wonder why they are spending so much money without seeing a return on investment, so they discontinue using Nurse Case Managers altogether. Both are a mistake.


Here are some of the many ways Nurse Case Managers can help on a workers’ compensation claim:


  • Advocate and educate. The best reason to use a NCM is to help an injured worker who is frightened, confused and angry — often a recipe for litigation. The NCM can educate and advocate for the injured worker and guide him through the entire process, so he knows what to expect. The NCM can also inform employers on how the injured worker is progressing, and work with the treating physician to make sure the worker is getting appropriate care.


  • Flag potential problems. If the injured worker has psychosocial or pain management issues or needs durable medical equipment, the NCM can spot that early in the claims process and help coordinate the necessary treatment.


  • Communicate with all stakeholders. The NCM can keep everyone in the loop, so necessary details don’t fall through the cracks.



When to Use Nurse Case Managers


Simple, medical-only, and claims where the injured worker is highly engaged and anxious to return to full duty as quickly as possible do not signal the need for a NCM. On these and other cases the addition of a case manager is unnecessary and a waste of money.


More complex claims are where Nurse Case Managers can have a significant impact. Certain claims should trigger involvement from a NCM, including:


  1. Lost time. Workers who are off the job for more than a couple of days can benefit from extra involvement. A NCM can answer the injured worker’s questions and ensure he is complying with the treatment plan.


  1. Surgery is needed. Even if it is a medical-only claim, the need for surgery should be a red flag to get a NCM on the claim. There will be many things going on, such as preparing at home, the need for and type of pain medications after, and any DME that might be temporarily needed. The NCM can coordinate the various moving parts.


  1. Failing to attend scheduled medical appointments. Whether the worker is off the job or working in some capacity, failing to see treating physicians, physical therapists and other providers is a sign there may be a problem. A NCM can contact the injured worker and either get the person to comply or find out if there is an underlying problem that should be addressed.


  1. Comorbid Conditions. An injured worker with diabetes, obesity, hypertension or other comorbid conditions is prime for a more complicated claim. A NCM can help keep the claim on track.


  1. Uncooperative treating physician. If the injured worker’s primary physician continues to say the patient needs to stay out of work entirely, a NCM can intervene, find out why the person is not recovering, and explain return-to-work principles — such as light duty and employer accommodations.


  1. Catastrophic and/or multiple injuries. These claims involve many people and moving parts. A NCM can be the go-to person for all parties involved, including the injured worker and his family. The NCM can also make any arrangements needed, and keep costs down by selecting the most appropriate equipment.



When to End NCM Involvement


Putting a NCM on a claim doesn’t need to be a long-term prospect. These can be short assignments — even just one or two visits or calls. Depending on the complexity of the claim and ongoing issues, the NCM may need to contact the injured one time to keep him on track and in compliance with medical appointments; or may need to reach out to the treating physician for something simple; or discuss accommodation possibilities with the employer. The earlier a NCM intervenes in a claim, the shorter the assignment typically is.


You can gauge when the NCM is no longer needed, for example:


  • The injured worker is back to work in at least a light duty capacity
  • Stakeholders are communicating well with one another
  • Restrictions are decreased, and the worker is progressing well





Nurse Case Managers can add tremendous value to a claim, generating optimal outcomes for injured workers and lower costs for payers. But it is not a black and white issue; meaning they don’t need to intervene in every single case, and they don’t need to be involved indefinitely. Thinking through a strategy for using Nurse Case Managers can have a significant impact on claims.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .


Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/


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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.


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