When to NOT Use Nurse Case Management in Work Comp

Countless studies demonstrate that nurse case management can be used as an effective tool to reduce workers’ compensation costs. While there are many benefits to using these services, interested stakeholders should keep in mind that there comes the point in the life of a claim when it no longer becomes necessary. The claiming team needs to recognize when the value of a nurse has run its course to save on workers’ compensation program costs.

What is Nurse Case Management Services?

Nurse case management is a service that involves a nurse coordinating efforts with the claim management team to manage a file and ensure the employee receives appropriate medical care and treatment following a work injury. These services can be provided in person or via telephone to interact with all interested stakeholders on a claim.

Not all claims require the services of nurse case management. Cases where it should be considered, include:

• Instances where an employee is missing medical appointments;
• Claims, where predictive analytics suggest the employee will miss prolonged time from work;
• There is an underlying psychological and/or psychiatric component that is a barrier for the employee;
• The medical care provided or recommended to the employee is not consistent with clinical guidelines; and
• The employee has significant pre-existing conditions or comorbidities.

The bottom line is that a nurse case manager can be used effectively to reduce workers’ compensation costs by ensuring the employee is receiving medical care and progressing toward getting back to work.

Red Flags that Nurse Case Management is no Longer Effective

Studies demonstrate that nurse case management has many benefits. These include:

• Reducing the rate of ligation in workers’ compensation claims;
• Increases the engagement of interested stakeholders in the claim; and
• Get the injured employee back to work faster.

There is a Law of Diminishing Returns when it comes to nurse case management. When used for longer than needed, excessive money is spent on the claim, and efficiency in the program is lost. The bottom line is money is being spent that could be used to settle other workers’ compensation claims. Members of the claim management team need to understand when nurse case management is no longer effective and must be stopped.

• Return to work: There is little value in prolonged nurse case management services when the employee has made sufficient progress in returning to work. This can also include instances where the employee works a light-duty position and no longer requires constant or frequent contact. As a general rule, services should be stopped entirely once an employee returns to work without restrictions for 7-10 days.
• Loss of Purpose: The nurse case manager plays a vital role similar to an air traffic controller. They play a critical role in ensuring collisions or accidents do not happen. There is a point when the manager’s need decreases and is merely an unnecessary “middle man” in the workers’ compensation claim process. When this occurs, a claim handler should consider significantly scaling or terminating services.
• Reconsider the Approach: Nurse case management services can be provided in person or via telephone. More complex cases require more personal attention. If that additional attention is not required, interested stakeholders should consider a shift in how services are provided. There may be an opportunity for the claim team to reconsider their approach and look at the efficiency of services being provided in person. Telephonic nurse case management services should be used in claims where the employee has made a successful return to work or there is a reduction in the frequency of medical care.

Members of the claim management team need to be proactive when it comes to the use of outside services. This can also be an opportunity for dynamic claim teams to consider adding internal nurses to their teams.

Conclusions

Nurse case management services are an effective tool for reducing workers’ compensation program costs. It is also effective in getting an employee back to work. There does come the point where the type of services needs to be changed or eliminated. Claim handlers who evaluate and note where the employee is in a claim’s cycle will allow better decisions to be made and ultimately reduce program costs.

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 the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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