Complex and severe injury claims are a leading driver of workers’ compensation claims costs. The greater the complexity and severity of an employee’s injury the larger the number of medical providers involved in the medical treatment. The primary physician often engages other specialists, therapy services, diagnostic testing, pharmacy usage, etc. The result of involving many different medical providers in the injury claim is the primary physician is often not fully aware of all aspects of the injured employee’s medical treatment.
Doctor Standard Treatment Protocol Not Designed in Employees Best Interest
A primary doctor has many individual patients, making it difficult to impossible to spend the time evaluating the overall best course of medical treatment for a particular injured employee. To compensate for the limited amount of time a physician can spend with any one patient, it is the doctor’s normal practice to follow a standard protocol for each injury type. These standard treatment protocols tend to have various built-in tests and procedures designed not in the best interest of the injured employee but designed to protect the doctor from claims of negligence and/or medical malpractice when the injured employee does not achieve expected results.
Senior Nurse Reviewer Provides Medical Expertise to Help Adjuster Make Good Decisions
Workers’ compensation adjusters often wonder if all the diagnostic tests, therapy sessions, injections, prescriptions, and repetitive office visits are really worthwhile. Adjusters, not being trained medical professionals, may doubt the need for various medical procedures and attendant costs but are without the skill set needed to discuss with the primary medical provider the various medical services being utilized. Fortunately, there are workers’ compensation medical professionals – senior nurse reviewers – who have the expertise to review with the primary medical provider, and all other medical service providers, the need for each medical service provided to the injured employee.
Senior Nurse Reviewers – nurse case managers with the highest level of medical expertise and experience – assist employers, adjusters, medical providers, and severely injured employees with guidance and coordination of complex injury claims. By overseeing the medical care and coordinating medical treatment, the senior nurse reviewer reduces or eliminates unneeded medical services while the injured employee receives all necessary medical services promptly.
A senior nurse reviewer reduces claim costs in a variety of ways, including:
• Assisting the injured employee in the navigation of the medical universe.
• Facilitating communication between the injured employee, the medical providers, the adjuster, and the employer.
• Creating a care plan for the injured employee and updating the care plan as needed.
• Questioning and addressing unnecessary medical treatment.
• Keeping all medical care on track, eliminating delays in treatment, thus reducing the time the injured employee is off work.
• Coordinating the timely delivery of diagnostic testing, therapy, and medical appointments with other medical specialists.
• Providing on-going case oversight to eliminate unnecessary medical services.
• Identifying and addressing obstacles to the employee’s recovery.
• Addressing any deviation from established disability duration guidelines.
• Facilitating the quickest possible light duty or full duty return to work for the employee.
Senior nurse reviewers are not physicians but nurses with many years of experience. If the senior nurse reviewer and the medical provider disagree on what is the best interest of the injured employee, the senior nurse reviewer turns to doctors and medical specialists, who have contracted with the senior nurse reviewer’s company to provide a high level of expertise within their medical specialty. The senior nurse reviewer then has the contracted medical specialist consult with the injured employee’s doctor on a peer-to-peer basis to arrange for the best course of medical treatment for the employee.
Overall Impact of Senior Nurse Reviewer is Reduction in Claim Costs
The overall impact of using a senior nurse reviewer on complex and severe workers’ compensation claims is a reduction in the employer’s overall claim costs. The use of senior nurse reviewers results in two types of savings:
• Lower indemnity cost by the injured employee quicker return to work.
• Lower medical cost by eliminating unnecessary medical services.
For assistance in locating a senior nurse reviewer for your complex and/or severe claims, please contact us.
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 .
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