Nurse case managers can be invaluable to an injury management program. They can have a tremendous impact by helping organizations attain better outcomes for their injured workers and saving significant dollars.
But far too often industry stakeholders misunderstand how and when to use them. Like many aspects of claims management, Nurse Case Managers are a tool that should be employed judiciously and with forethought to garner the most value.
NCMs are not miracle workers. However, when incorporated into the right types of claims they can be instrumental in getting the injured worker healed and back to work in a timely fashion, resulting in the types of savings reported above.
Here are the many ways NCMs help with a claim:
- Patient advocacy. This is where NCMs shine. Injured workers are often confused and scared, especially if the injury is severe. Unlike being injured at home and going to see whatever physician they choose, the rules for injured workers are different. They are often told what doctor to see and when. They may also be concerned about how they will get money if they are out of work for any length of time. And they may fear losing their job. A NCM can guide the injured worker through the process, allaying his fears and answering his questions. They can
- Explain the process and restrictions
- Discuss likely recommendations from doctors
- Provide options for various specialists, regardless of the rules for physician choice in a jurisdiction. Where the injured worker has the option to visit any physician, the NCM can recommend physical therapists, orthopedists, or others. In employer-directed care states, the NCM can discuss various in-network providers known to her.
- Review meds. The NCM can explain the medications that are prescribed and look at possible interactions with other pharmaceuticals the injured worker may be taking.
- Reduce litigation rates. One of the benefits of NCMs is the trusting relationship they develop with the injured worker. Research shows injured workers who work closely with a NCM are much less likely to sue their employers.
- Increase engagement and ensure compliance. Injured workers can be notoriously unfaithful to the treatment plans — forget to take their medications, miss PT or other provider appointments, failing to do assigned exercises that aid recovery. Again, having a trusting relationship with a NCM who is clearly advocating for the injured worker is likely to result in better adherence to a treatment regimen.
- Communicate. Because he is closely involved with the injured worker, the NCM is the best person to act as the liaison to all stakeholders.
- With the employer. The NCM can keep the employer updated on the injured worker’s progress. He can discuss restrictions and ways the employer can accommodate the worker. He can also discuss the capabilities the injured worker has during the recovery process to help identify light-duty work.
- With the treating physician. Especially in states where workers have a choice of providers, the NCM can explain the workers’ compensation system and the emphasis on return to work.
- With the claims adjuster. The person handling the claim may be unaware that the injured worker has been released to return to work, for example, requiring a change in the benefits.
- ID then need for peer review. Sometimes claims go off the rails because the treating physician is not following evidence-based medicine guidelines, or doesn’t understand the goal of return to work. A medical provider who is not an occupational physician may continually say the injured worker should not go back to work in any capacity. The NCM can detect such incidents and get a medical provider from the insurer or third-party administrator to review the case and possibly talk with the treating provider.
- Coordinate interventions. Psychosocial issues may be present that could derail the claim unless they are addressed. The NCM may be the first person able to detect these and seek cognitive behavioral therapy or other intervention. A pain management program may be warranted, which the NCM can coordinate.
NCMs are one of the most effective ways to achieve best win-wins for injured workers and employers. But it’s important for stakeholders to know how and where they can add value. For example, they should not be used on every claim.
Author 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 .
Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/
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