Reduce Work Comp Costs Through Effective Medical Care

medical relationshipThe largest portion of any workers’ compensation claim is medical costs associated with a work injury.  While these figures vary in each jurisdiction, providing effective medical care and treatment for employees remains a challenge.

 

 

Start With Effective Post-Injury Response

 

Top performing claim management teams know from experience that the best way to reduce and manage the medical costs of any work injury starts with an effective response following an incident.  This includes a number of factors that can be implemented by all stakeholders.  While on-site medical care is preferable, it is often not realistic.  Here are some important pointers to implement within the workplace:

 

  • Proper training for all employees on how to report and respond to a work injury;
  • Commitment from employers and management on dealing with injuries;
  • Basic first-aid training and equipment that is accessible to all employees; and
  • Preparation of an injury response plan.

 

 

Develop Local Health Care Facility Relationship

 

An injured worker does not usually require emergency medical care and treatment.  It is important to provide all employees with accessible medical care and treatment at a local health care facility.  A proper evaluation of this facility should include the following:

 

  • Competent medical staff that can properly diagnosis and commence medical care and treatment for the most common injuries;
  • A strong referral network of specialists who are training to treat a variety of injuries. This includes doctors who have a background in orthopedic medicine, neurology, psychology/psychiatric care and other “sports medicine” specialties;
  • Medical facilities that communicate with all interested stakeholders, including the claims management team and employer representatives.

 

 

Other Trends in Medical Cost Containment

 

The use of managed care models in workers’ compensation has proven to be an effective tool in providing quality medical care and treatment, along with cost containment strategies.  Under this system of care, the managed care program is charged with the responsibility of developing a network of doctors, surgeons, chiropractors, osteopaths, podiatrists, physical and occupational therapists, and other specialists to provide medical care and treatment to injured workers.  This can also include the designation of specifically medical clinics and hospitals were employees are required to receive their care.

 

Laws and other administrative rules governing managed care programs vary in each jurisdiction that allows these arrangements.  Workers’ compensation laws typically allow employees to choose the doctor(s) they see for care.  In other instances, they are also allowed to go outside the established network.

 

There are a number of benefits to a manage care model in a workers’ compensation program:

 

  • Allows for a more holistic approach to care and provides for care coordination and utilization review of treatment;
  • The use of case managers allows for better communications between all interested stakeholders in the process. This manager can also help answer questions for parties who lack experience or knowledge of the workers’ compensation process; and
  • Coordination with other professionals in the workers’ compensation process. This can include a coordinated effort in return-to-work matters and the evaluation of work restrictions.

 

 

Conclusions

 

Access to quality medical care and treatment is a right every employee has following a workplace injury.  This can sometimes be at odds with the interests of other stakeholders.  Seeking creative solutions and being proactive is one step every employer should take to consider the interests of their workforce and protect their bottom line.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

 

What, Exactly, Is Influenza?

The Centers for Disease Control and Prevention (CDC) describes the flu as a contagious respiratory illness that can cause mild to severe symptoms and at times can lead to death.

 

Common flu symptoms include fever, cough, sore throat, runny or stuffy nose, muscle and body aches, headaches and fatigue. Symptoms can also include vomiting and diarrhea.

 

 

How does the flu spread?

 

The flu spreads primarily from mucus or saliva droplets during coughing, sneezing or talking. Droplets can travel up to 6 feet, person to person, landing in the mouth and nose, or are inhaled into the lungs of the uninfected person. People can also get the flu when they touch contaminated surfaces and objects, like telephones or countertops that have the flu virus on them, and then touch their own mouths or noses.

 

Flu symptoms can start within one to four days after being infected and last upwards of one week. The flu can be spread for up to seven days or longer by children. Surprisingly, some infected individuals show no symptoms at all. The CDC stresses that this means you may be able to pass on the flu to someone else before, or without knowing you are sick.

 

 

How can I protect myself and others?

 

The CDC wants everyone to know that best way to prevent the flu is by getting a flu vaccine each year. Everyone six months or age and older should get the flu vaccine.

 

The Centers for Disease Control stresses that the best way to avoid contracting the influenza is to get a flu shot.

 

 

The following are six simple steps for flu prevention:

 

  1. Wash hands with soap and water. Use an alcohol-based hand rub when soap and water are not available.
  2. Stay home if you are sick.
  3. Avoid close contact with sick people.
  4. Cover your mouth and nose when coughing or sneezing.
  5. Avoid touching your nose or mouth.
  6. Clean and disinfect frequently touched surfaces and objects.

 

 

Author Gregg Cognac, PA-C, Clinical Affairs Director, Medcor is a certified Physician Assistant, and works with Medcor’s medical directors to provide oversight and support for on-site clinic staff in more than 170 locations nationwide.  Gregg earned his degree in PA studies from Midwest University in 1999, then completed post-graduate training in Emergency Medicine culminating in a Master’s degree.  Gregg’s clinical experienced has been in Emergency Medicine, Occupational Medicine and Cardiology.  Gregg contributes to policy and service development, QA, training, and other clinical support for clinic staff operating in a wide range of industries. http://medcor.com.  Contact: gregg.cognac@medcor.com

Reducing Workers’ Compensation Costs through Managed Care

In the quest to reduce costs and maintain the quality of care an injured worker receives, managers of workers’ compensation programs seek the assistance of managed care programs.  By using managed care techniques, managers can provide quality medical services to injured workers, while at the same time promoting the objectives of their company.

 

 

What is a Managed Care?

 

The term “managed care” has been around in American society for quite some time.  In the 1970s, the term was coined as a concept to describe a methodology used to reduce the overall costs of health care benefits through organizations or techniques from organizations within the health care system.  At the core of any managed care program is the ability of a program such as workers’ compensation to finance and deliver services while at the same time meeting statutory requirements as set forth in law.

 

 

Managed Care through a Preferred Provider Organization

 

A Preferred Provider Organization or PPO is a type of managed care program that is similar to other network-based managed care program such as a Health Maintenance Organization (HMO), Private Fee-For-Service (PFFS) or Point Of Service (POS) program.  In the context of a PPO, in order to remain competitive, that organization must seek out medical facilities that will provide medical services at a discounted rate.  These medical facilities are able to offer such discounts based on the volume of clients and the number of people they serve.  While services are typically only offered at “preferred” medical facilities, the standard of care is the same based on the ethical obligations of medical providers.

 

 

Features and Advantages of PPOs

 

PPOs generally evaluate the need for ongoing care based on utilization review of medical services and care provided to an injured worker.  The use of utilization review examines the nature and extent of an injury and analyzes the care one typically would receive based on information collected over a long period of time.  The use of utilization review is especially important when it comes to the use of narcotic pain medications and diagnostic procedures that continue to be a driver of rising medical costs.

 

Unlike other forms of managed care, PPOs maintain their advantage as follows:

 

  1. Membership tends to provide substantial discounts for routine medical services;
  2. Networks create a number of options, including primary care doctors and specialists for injured workers to receive medical care and treatment;
  3. Treatment received outside a PPO network is generally not as expensive when compared to the same care received in other managed care formats;
  4. They have broader networks than HMOs and allow injured workers to receive care within a greater geographical area.  This is especially helpful to employers with workers in rural areas.

 

Conclusions

 

Although workers’ compensation claims in general have been in a decline for the last few years in the United States, employers and insurers are seeing a steady uptick in more severely injured persons.  As a result, effective workers’ compensation programs need to be creative in how they approach the complex claims environment to control costs, which is really the bottom line for any programs.  By using a Preferred Provider Organization, claims and risk management teams are able to address these issues without sacrificing the quality of care an injured worker receives.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 
Editor 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: mstack@reduceyourworkerscomp.com.

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

Impact of Affordable Care Act on Workers Comp: Highlights From WCRI

The theme of this year’s WCRI conference was Upheaval in the Market for Health Care – Facts & Myths. I must say, they did not disappoint. This conference was packed with highly qualified speakers, and thought-provoking content. In the very politically charged topic of health care, the speakers stuck with the facts and it only became political if the individuals in the audience interpreted the material that way.

 

 

Affordable Care Act Taught By An Expert

 

The conference started with what I think was the highlight of the two days, a session presented by Professor Jonathan Gruber from MIT. Professor Gruber was a key architect in Massachusetts Healthcare Reform, as well as helped to craft the Patient Protection and Affordable Care Act. He told a story that resonated with the audience. Here’s a condensed version: “I was riding in a taxi cab and the driver wants to tell me about the Affordable Care Act. There is no way this driver knows more about this than I do.”

 

This resonated because those of us in the audience could relate to the taxi driver. We listen to the republican leaders about how terrible this program is, and the democratic leaders about how great it is. But, I would guess there are few of us who have read all of the details of the act to fully understand it. Professor Gruber was right, we don’t know as much as he does, he is a clear expert in this field. Listening to him speak was both entertaining and educational. Here is a bullet point summary of his points:

 

  • Our current health care system works, but not for 100% of Americans.
  • The two problems with the system: 1) having ability for all Americans to get insurance 2) controlling costs.
  • The federal system is a much larger and more robust version of the Massachusetts system. The MA system figured out how to solve problem 1 with less than 2% uninsured. Controlling costs is a more difficult problem to solve.
  • Health care costs have risen significantly to 18% of our GDP, but so has the quality of care. 2/3 of health care spending is effective, 1/3 is wasted. It is difficult to identify what the 1/3 is.
  • The ‘Cadillac tax’ has the highest probability to control health care costs. The provision targets health plans that provide workers the most generous level of health benefits to discourage over-consumption of health care.  It also addresses the unequal tax benefit where wages are taxed, but health benefits are not.
  • # 1 issue in health care reform is price structure
  • This act is still very new, it will take around 3 years for us to see the real impact of this law. It is critical that we are humble and patient with health care cost control.

 

 

Professor Gruber’s Take on the Impact of Affordable Care on Workers Compensation

 

1) The Affordable Care Act will decrease cost of workers compensation. More workers will be covered by health insurance, thus there will be less incentive to attempt a fraudulent claim to have health care covered by workers compensation.

 

2) The Affordable Care Act will increase cost of workers compensation. Health care providers get reimbursed more from workers compensation, so they will shift care to workers compensation to receive a higher fee.

 

 

Affordable Care Act’s Impact on Workers Compensation: Highlights from Rest of Conference

 

  • “Affordable Care is a great opportunity to have dialog with health care providers to get better health care for injured workers. As business owners, we don’t have the luxury of waiting a few years to see what happens”. – David North, Sedgwick Claims Management Services, Inc.

 

  • “It is more important than ever to partner with the right health providers. Look at outcome based networks, it is not about the dollar, it is about the outcome.” – Don Hurter, AIG

 

  • “Massachusetts has the lowest % of uninsured, and the most doctors per capita of any state. MA may or may not be a good predictor of other states. The demand for health care is increasing while the supply of doctors is remaining relatively fixed. Lack of doctors will have the biggest impact on high volume/low severity claims by potentially delaying treatment and increasing the cost of the claim. We could see accelerated medical inflation due to the impact of supply and demand”. – Christopher Cunniff, Liberty Mutual Insurance

 

  • Accountable Care Organizations may be the most logical program I have heard in regards to health care. Dr. Sreekanth Chaguturu, Partners HealthCare gave a presentation on their program and its benefits. Simply, the goal of accountable care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. The provider has financial incentive to control costs and ensure patients receive appropriate care. That, to me, just makes sense.

 

The conference attendance was at an all time high, and I understand why. Overall, it was a great presentation by WCRI. I look forward to attending again next year.

 

 

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: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

Quality Physician Review Services Produce Staggering Return On Investment

Proper evaluation of the medical treatment an injured employee receives is one of the most daunting tasks facing either the self-insured employer or the workers’ compensation claims adjuster. When a medical provider makes a statement regarding the nature and extent of an employee’s injury, the tendency of most people is to accept the medical provider’s statements at face value. In states where the injured employee (or the employee’s attorney) selects the medical provider, the acceptance of the medical provider’s diagnosis, prognosis, and recommended treatment without question can be a serious and costly mistake.

 

 

Physician Review Services Determine Most Appropriate Medical Care

 

Fortunately, the better medical management organizations offer physician review services (PRS) to address whether or not the injured employee is receiving the most appropriate medical care for the injury incurred. These are objective peer-to-peer review services where a highly qualified physician assesses the accuracy and quality of the medical care by reviewing the medical history of the employee’s injury and any comorbid factors influencing the needed medical treatments. By evaluating the medical necessity of medical services, the PRS prevents unnecessary medical treatment, saving both medical and indemnity costs by shortening the period of time the injured employee is off work.

 

In selecting a PRS, the workers’ compensation adjuster or the self-insured employer looks for the following characteristics:

• A reputation for professionalism.

• Credentialed and board certified highly experienced physicians.

• A large panel of diverse physicians.

• Physicians who understand workers’ compensation.

• A panel covering all major specialty areas.

• Multiple panel physicians in the larger specialties.

• A panel providing thousands of determinations each year.

• The PRS is accredited by the Utilization Review Accreditation Committee (URAC).

 

 

URAC accreditation is important because both certification organizations establish quality standards for evaluating and assessing medical care. IRO and URAC require the PRS to have quality benchmarking programs keeping pace with rapid changes in the medical field. Both IRO and URAC require the PRS to have continuing education, ensuring the physicians are up to date on the latest medical treatment methods.

 

When a PRS utilizes a credentialed, board certified highly experienced physician to evaluate the medical care an injured employee receives, it identifies when the employee’s medical provider is exhibiting inadequate medical knowledge of the best treatment methods for that injury. The PRS physician also identifies any situation where the treating physician is deviating from the standard of medical care needed by the injured employee. (Frequently when a medical provider is struggling with the best course of treatment for an injured employee, the medical provider appreciates the PRS physician’s input and guidance.)

 

Rebecca Shafer, President of Amaxx Risk Solutions, states ”Ever since managing the claims of a Fortune 500 organization, I have used MD’s as an indispensable part of my program. Quite often we forget that workers compensation claims are medical injuries, and the best qualified person is often a medical doctor.”

 

 

Return on Investment From Top Quality Physician Review Service

 

It is a costly mistake, as noted above, when PRS is not used to manage and control the medical cost in a workers’ compensation claim. The return on investment of top quality physician review services can be impressive. Data provided to us from Broadspire’s medical department show the following figures:

o Medical necessity/appropriateness of requested services: 3.9 – 1.0

o Medication reviews (prior authorization non formulary): 8.1 – 1.0

o Medication reviews (comprehensive pharmacy): 48.9 –1.0

o Return to Work / MMI: 43.4 –1.0

o Impairment rating validation: 5.7 – 1.0

o Appropriateness of treatment plan: 29.9 –1.0

o Causality determinations: 378.2 – 1.0

o Functional Impairments (STD / LTD): 99.3 –1.0

o Medical Bill Review (hospitals; ambulatory surgery facilities): 89.4 – 1.0

 

 

Physician review services are especially important on long-term or severe injury claims. The use of a PRS is recommend any time there is a question about the validity, length, or quality of medical treatment.

 

For assistance in identifying and selecting a Physician Review Service, please contact us.

 

 

Author Michael B. Stack, CPA, Director of Operations, 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: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.


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

Effectively Manage Medical Management

Medical management companies, when properly utilized, are an excellent way of controlling the cost of workers’ compensation claims. The underutilization of medical management results in unnecessary overpayments for medical services. However, the over-utilization of medical management can result in unnecessary payments to the medical management companies for services that do not have a positive impact on the overall outcome of the claim. When employers pay for services not needed, the savings normally achieved through medical management are reduced or even eliminated.

 

 

Should Seek Optimum Balance Between Underutilization & Over-Utilization

 

Achieving the optimum balance between underutilization and over-utilization of medical management services can be difficult on occasions, but is well worth the effort.

 

Underutilization of medical management often occurs when medical triage is not provided at the start of the claims, when utilization reviews are not completed on medical services being provided, when medical bills are not reviewed, and when nurse case managers are not on the claim. Each of these medical management services can reduce the overall cost of the claim.

 

Over-utilization most frequently occurs when nurse case managers are used indiscriminately. This occurs when the employer and the medical management company do not have predetermined guidelines on when to use the nurse case manager. Adjusters, who are frequently overloaded, are more than happy to assign a nurse case manager to handle the medical aspects of their claims.

 

When nurse case managers are assigned to an injury claim without a specific goal to achieve, their involvement is less focused. Proper utilization of nurse case managers includes either the adjuster or the employer providing direction to the nurse case manager on what the objective of the assignment is. For example: “coordinate the medical care between the primary doctor, the specialist, the therapist and the diagnostic testing to bring the injured employee to MMI in the minimum amount of time”, or “verify and limit medical treatment to what is necessary for the catastrophic injury”. If the adjuster just gives the nurse case manager the instruction to “handle the medical aspects”, the amount of time spent for medical case management will be higher than is otherwise necessary.

 

 

Predetermined Criteria Should Be Established To Utilize Medical Management

 

The way to achieve balance in the use of the medical management company’s services and reach the optimum level of expenditure for medical management is to establish parameters with predetermined criteria on when to utilize the services of the medical management companies. While some medical management companies may be reluctant to having parameters on when to use their services, most medical management companies will appreciate having precise guidelines. This eliminates many of the billing issues that can arise with the use of medical management. It also assists the medical management company in tailoring their services to fit the specific needs of the employer.

 

Written guidelines and policies outlining the expectations on when and how medical management will be used creates a smoother flow to the claim and eliminates areas of friction that result when the medical management company does not know the employer’s medical management policies. When both the adjusters and the nurse case managers know exactly when medical management will become involved in the claim, the overall claim management is easier.

 

Employers should strive for the optimum utilization of medical management on their workers’ compensation claims. It is not always easy to obtain the right balance of medical management. For assistance on medical management issues, please contact us.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

 

Editor Michael B. Stack, CPA, Director of Operations, 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: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

 


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

Top Notch Nurse Case Managers Create Best Return on Investment

Medical management is a well-established cost control technique for workers’ compensation. The use of nurse case managers to provide oversight of an injury claim facilities the medical treatment, speeds the recovery process and shortens the time until the injured employee can return to work.  The benefits of nurse case management are so potent, that almost all workers’ compensation programs now include nurse case managers.

 

 

Top Notch Nurse Case Managers Create Best Return on Investment

 

Due to the positive impact of nurse case managers, there are now numerous medical management companies providing the service.  Every one of the medical management companies providing nurse case managers can save the employer money.  However, there is a difference between the best of the medical management companies and all the rest.  Selection of the company providing the top notch nurse case managers can be the difference between a return on investment of 3 to 1 or a return on investment of 10 to 1.

 

 

To select the medical management company with the best nurse case managers, look for the following attributes:

 

  • The experience level of the nurse case managers is key.  While a nurse case manager with 5 years’ experience can be excellent at what he/she does, a nurse case manager with 25 years’ experience will probably be better.  Therefore, ask the medical management company you are considering:
    • What is the average number of years of nursing experience for the nurse case managers?
    • What is the average number of years of nurse case management experience for their nurses?
    • What is the average tenure the nurse case managers have been with your company?
    • A large support network is necessary.  While nurse case managers have extensive training, like doctors they are not experts in every medical specialty. As more than 25 different medical specialties can be involved in different types of work comp claims, the medical management company needs to have contracted physicians available to assist the nurse case manager in all specialty areas of medicine.
    • The medical management company must have nurse case managers in the vicinity where your company experiences work comp claims.  A great nurse case manager in another city or another state who does not know the local medical providers and medical facilities will be less effective than the local nurse case manager.
    • The nurse case manager should not only be local, they need to be experienced with the medical providers.  An experienced nurse case manager can quickly tell you which medical specialists get good results and which ones do not.
    • The field nurse case managers that are local to your facility also cost less over the long run.  If you are paying a nurse case manager who is more than an hour away from a facility, a disproportionate amount of the service bill will be for driving time, plus mileage.
    • The nurse case managers need to be willing to share with the employer not only what is in the medical reports, but their conversations with the injured employee, medical providers and others.  This provides insight into what the claimant and medical provider are saying and thinking.
    • The nurse case managers need to be willing to share with you information that is “off the record”.  This includes observations and insights gathered from the actions of the employee or medical provider.

 

If you have multiple locations, larger medical management companies will have better geographical spread, are more likely to have more experienced nurse case managers and will have more contract physicians covering more specialties.  For assistance in selecting medical management companies with the best nurse case managers, please contact us.

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 
Editor Michael B. Stack, CPA, Director of Operations, 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: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.


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

How To Build A Relationship With A Preferred Provider Organization

Introduce the Preferred Provider Organization to Your Company
A preferred (sometimes “participating”) provider organization or PPO is a managed care organization that agrees with a third-party administrator or insurance company to provide their clients with reduced rates. PPOs are a group of doctors, hospitals and other medical providers who work together to provide medical care for an injured employee at a pre-agreed reduced price. Usually, PPO networks discount each unit of service, which reduces claims costs. In addition, there are preferred services so that employees are treated promptly with little waiting time, and are treated well — almost like a preferred customer. Their medical providers should have occupational medical experience and regard return to productive employment as the top priority.

 

As with the rest of your company’s workers compensation and safety programs, your supervisors and employees should know the benefits your company seeks to provide by choosing a PPO:

 

  • Immediate medical attention
  • Minimizing further injury or medical complications
  • Continued employment
  • Maintaining morale and eliminating problems for the employee while they are injured
  • Keeping the company financially viable helps everyone

 

When you train your employees and supervisors on your company’s workers compensation and safety programs, make sure you include information about your PPO network. Make sure your Employee Introduction Letters and What to Do If You Are Injured on the Job Brochures and Wallet Cards include the PPO information and mission to provide your employees with the best medical care and quickest recovery.

 

 

Introduce Your Company to the PPO

 

Your company’s general manager needs to create a personal relationship with the PPO clinic that provides medical care to your employees. We recommend that you invite the clinic director and administrator to your physical work site for a visit.

 

Establishing this relationship helps put your company’s priorities into focus. It is always best to have a face and place in mind when accomplishing any job, especially one involving employee health. You want clinic personnel to know your company, workplace settings, job requirements and your management’s approach.

 

Send an invitation in writing, including all your contact information as well as your employee and provider brochures.

 

Tips:

  • Be polite.  Let the clinic know you are pleased they are part of your insurance network.
  • Express that quality of care in your company is a top priority.
  • Let them know you want to be prepared when injuries occur, but let them know this is not a frequent event.
  • Explain that the company offers a transitional duty program and you need the PPO’s cooperation.
  • Ask if the PPO administrators would be willing to visit your facility to meet employees, view work conditions and see the jobs employees perform.
  • Finalize by asking that they email you to suggest a date for such a meeting.

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, 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: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.


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

When to Use a Nurse Case Manager

A high percentage of self-insured employers and insurers make the mistake of allowing the adjuster to use his or her own discretion on when to use a nurse case manager on a claim.  This can result in the medical cost and medical treatment getting out of control because the nurse case manager is not brought into the claim timely.  Studies by Broadspire and other medical management companies have shown the return on investment of a nurse case manager to be anywhere from 3 to 1 to 20 to 1. 

 

Specific Guidelines Should Be Established

 

Instead of allowing the adjuster discretion on when to utilize a nurse case manager (the adjuster is normally late in making the decision to use a nurse case manager), it is better to set specific guidelines on which claim files should have a nurse case manager assigned.

There are two types of nurse case managers.  The nurse case manager who works from an office and handles all of the work by telephone, email, fax and regular mail is normally referred to as a telephonic case manager or TCM.  The nurse case manager who works in the field, meeting in person with the injured employee and the medical provider(s) is referred to as a field case manager or FCM.

 

Criteria To Trigger Use of Nurse Case Manager

 

Common criteria used to designate or trigger the use of a nurse case manager includes:

 

  •          Immediate hospitalization after an accident
  •          Amputations of fingers or toe
  •          Second degree burns over a limited skin area
  •          Electrocution
  •          Concussions
  •          Vision impairment
  •          Immediate loss of hearing
  •          Heart attack on the job (if the claim is compensable)
  •          Stroke on the job (if the claim is compensable)
  •          Rotator cuff or other shoulder injuries
  •          Meniscus or other knee injuries
  •          Ankle sprains
  •          Back injury claims
  •          Neck injury claims
  •          Joint dislocation
  •          Carpal tunnel syndrome
  •          Tendonitis
  •          Fractures that require time off work
  •          Hernias
  •          Asbestosis, pneumoconiosis and other occupational lung diseases
  •          Occupational skin diseases caused by chemical exposure

 

 

Criteria To Use a Field Case Manager

 

While either a Nurse Case Manager or a Field Case Manager can provide case management services on the above types of claims, there are some situations where it is better to have a Field Case Manager involved in the case management.  This includes:

 

  •          Attendance at independent medical examinations
  •          Attendance at doctor appointments
  •          When the employee has been referred by the initial medical provider to a specialist
  •          Brain and brain stem injuries
  •          Catastrophic injuries
    •    Spinal cord damaged or severed
    •    Amputation of hand, arm, foot, leg
    •    Third degree burns or burns over 25% or more of the body
    •    Total loss of vision
    •    Multiple amputations
  •          Multiple traumas from the accident
  •          Narcotic addictions
  •          Employee’s failure to improve medically during the course of treatment
  •          Suspected improper course of treatment of inadequate treatment
  •          Employee non-compliant with doctor’s instructions
  •          Employee missing medical appointments

 

Benefit of Medical Case Management Is Well Established

 

As the benefit of medical case management is well established, some self-insured employers and insurers are taking the decision on whether or not to use a nurse case manager out of the adjuster’s hands, and mandating when medical case management will be used.  When the insurer or self-insured employer takes this approach, they will either assign a nurse case manager to all indemnity claims, or have the medical case management company review all reported workers’ compensation claims and select those where the Telephonic Case Manger or the Field Case Manger can make a difference.

We recommend medical case management on any claim where the injured employee meets any of the medical treatment guidelines outlined above.  For assistance with when to use a nurse case manager, or when to decide between using a Telephonic Case Manger or a Field Case Manger, please contact us.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com

 

Editor Michael B. Stack, CPA, Director of Operations, 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: mstack@reduceyourworkerscomp.com

 

©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.  


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

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de