Improve Your Bottom Line With Nurse Triage

Nurse Triage Uses Experienced Nurses to Determine Care


Nurse triage is a concept workers’ compensation has adopted from outside traditional health insurance and claims management fields to control of the cost of medical care.   Nurse triage is the use of experienced nurses, clinical algorithms and software to determine the appropriate level of medical care injured employees need.  While nurse triage can be utilized any time in the course of the workers’ compensation claim, it is most effective when it is conducted immediately after an injury — before the injured employee seeks care that could be too little or too much.



No Extra Care “Just in Case”


When employers do not have nurse triage services available, immediately following an injury it is the employee or the employee’s supervisor who determines the level of medical care that is needed.  An employee, who is in pain from an injury, and with no medical training, will normally opt for the highest level of service available.  Supervisors may default to a higher level of care to mitigate their risk “just in case.”


With a nurse triage service, specially trained nurses are available 24/7 to evaluate the injury with the employee by telephone. The best services use highly trained nurses, and sophisticated software, to ascertain the severity of the employee’s medical symptoms and direct the employee to the most appropriate level of medical care.  By guiding the injured employee in the selection of medical care, costly hospital emergency room treatment or unnecessary clinic visits can be prevented.  More serious cases can be identified even when the employee may not recognize the severity.  Plus, when off-site medical care is needed, the employee receives recommendations on preferred “in-network” medical providers.



Triage Nurse Communicates with Relevant Stakeholders


The triage nurse communicates his/her involvement to the medical provider, TPA, and other stakeholders by telephone,  e-mail, fax or even secure server-to-server data feeds to maintain the continuity of the employee’s medical care. Nurse triage assists the medical provider, but it does not replace medical treatment provided by the medical provider. Nurse triage benefits the medical provider by allowing the medical provider to concentrate on the patients in the most need of the medical provider’s services. 


The triage nurses are trained and supported to utilize their critical thinking skills and listening skills to understand the employee’s medical condition, and evaluate the pain, anxiety and the employee’s understanding of their medical condition.  The triage nurses use their communication skills to explain to the employee the nature of their injury, the type of treatment needed and their knowledge of the expected recovery time.


The software used by the triage will contain a series of algorithms (a set of p for solving a problem in a finite number of steps) to assist in making the best recommendation for the employee, whether it is emergency care, an appointment with a medical provider, or self-care. In one provider’s patented process, the employee’s symptoms are evaluated by asking a series of questions beginning with the most acute and working downward to the least acute.  Depending on the employee’s answers, the algorithms guide the triage nurse to the proper level of medical care.  When the employee needs more than self-care, the triage nurses are trained not to give the employee a diagnosis, but to direct the employee to the most appropriate medical provider.



Ways Triage Improves Bottom Line


In addition to reducing cost by sending the employee to the proper level of medical care, the triage nurse improves the bottom line by:


  • Increasing the percentage of self-care, reducing claim volume


  • Reducing the number of injuries that become OSHA reportable (by avoiding unnecessary medical claims)


  • Increasing the number of claims handled through the medical provider network


  • Reducing the employee’s time off work, increasing productivity


  • Improving morale by having a trained nurse available immediately when an employee is injured


  • Reducing the occurrences of fraud (triage provides immediate documentation of incidents, and the best systems record the call)


  • Providing round-the-clock control of medical treatment for employers who have multiple work shift


  • Identifying potential life threats and serious cases not recognized by injured employees.



Check Accreditations Before Selecting Triage Service


When selecting a nurse triage service, the employer should look for triage providers who can verify their competency with experience, references, and the proper medical accreditations and certifications.  URAC (previously known as Utilization Review Accreditation Commission, but now known only by their acronym URAC) is the largest accrediting body for health care.  URAC offers many types of accreditation; triage is covered under the “Health Call Center” category.  If the triage provider has a URAC accreditation for Health Call Center, you will know the company is performing in accordance to national standards.


Amaxx can assist you in locating a nurse triage service to meet your medical cost control needs and improve your bottom line.



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:


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. Contact






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


©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at:


Eight GREAT Techniques to Control Workers Compensation Medical Costs

The cost of medical care is the largest part of the total cost of workers compensation. Finding ways to control and manage these medical costs is important to maintain and control workers compensation cost. There are numerous techniques to use to control medical costs.
Let us look at the ones providing the most benefit to the employer:
1. Nurse Case Managers
The most important person in the control of workers comp medical costs is the Nurse Case Manager (NCM). The NCM is responsible for planning and coordinating medical care to assist the employee in returning to work as soon as physically able or when the employee reaches the maximum medical improvement (MMI). The NCM role can either be in the office handling most communications by telephone — a telephonic case manager (TCM); or the nurse can spend most of her (or his) time away from the office — a field case manager (FCM) who attends medical appointments with the injured employee.   (WCxKit)
Whether the nurse is referred to as a NCM, TCM, or FCM, the role is to make sure the employee receives all necessary medical care as quickly as possible. The responsibilities of the NCM include:

1.      Consulting with the medical providers on the best options for treating the employee.

2.      Coordinating the medical care between the different medical providers.

3.      Preventing the over utilization of medical care while ensuring the employee receives all needed care.

4.      Acting as a liaison between the employee, employer, physician, therapist, insurer, and other parties.

5.      Facilitating the communications between the employee, employer, and adjuster.

6.      Arranging the employee's return to work either in modified duty with the necessary accommodations or full duty without any accommodations.

7.      Keeping the adjuster and employer informed as to the employee's medical status.

2. Medical Provider Networks
When various medical providers including doctors, hospitals, physical therapists, and others join together for the purpose of providing medical care to a specific group (employees), a medical provider network is formed. In exchange for sending all injured employees to the medical provider network, the employers or insurers receive a group discount on the cost of medical care. California and Texas are the two biggest states where medical provider networks are utilized to control the cost of workers compensation. Follow the rules exactly, and you can direct care for the life of the claim in California. In California, these are called MPNs.
3. Medical Triage
Medical triage is the process of having a trained nurse arrange the medical care for any employee who reports an injury. The triage nurse coordinates the medical care for the employee, arranges for the initial medical visit and any follow up visit, and advises the adjuster on the nature of the injury and the type of initial care received by the employee. Approximately 40% of your claims will be "self care" claims, which means you'll have 40% fewer claims, many of which would have ultimately become lost time claims. It's a way to stay on the claim from Day 1. Nurse triage can even direct the employee (and supervisor) to the nearest PPO in your network – if allowed by state law.
4. Utilization Reviews
Utilization review is the review of medical care by another party other than the medical provider to ensure the appropriateness of the medical care. There are three types of utilization review.

1.      Pre-certification: the requested medical service whether hospitalization, surgery or diagnostic testing, is reviewed by a trained nurse or doctor, to verify it is the best medical approach for the injured employee's medical care, before the medical care is provided.

2.      Concurrent reviews: occurs when the employee is in the hospital is having any other medical care that takes enough time for the medical necessity to be checked before it is completed.

3.      Retrospective reviews: verifies the need for medical services already provided.

5. Medical Fee Schedules
In an effort to control medical costs, most states place a dollar cap on each type of medical service an employee can receive following an injury. A medical bill review company compares all medical bills submitted against the fee schedule to insure only appropriate services are billed and billed for the correct amount. Most states have their own fee schedules – which is generally a very large, complex list (like a phone book) of codes for each injury/illness and treatment.
6. Pharmacy Benefit Managers
Pharmacy benefit managers (PBM) specialize in providing the employee with needed prescription medications. The PBM arranges for the employee to obtain prescriptions at drug stores within the network, or provides to the employee, by mail, any maintenance medications the employee will take over an extended period of time. PBMs can help control the overuse of prescription medication and curb opioid abuse.
7. Medical Panels
Several states allow the employer to designate a list of medical providers the employee can select from when the employee is injured. This panel of doctors includes a variety of medical specialties and/or medical facilities. The medical panel is normally posted at the employee's work site for the employee to chose from. This is sort of a blend between employee selects their own provider and employer selects the provider. Which ever state/s you are in make sure you know how medical provider selection is done.
8. Independent Medical Evaluations (IME)
An independent medical examination is a second opinion from a doctor selected by the insurance company to confirm the diagnosis and treatment of the employee. It can also be used to verify the disability or impairment of an employee when the employee finishes medical care. (WCxKit)  Have an MD write the IME cover letter and point out to the IME doctor relevant causation issues and/or mechanism of injury issues that make be disproportionate to the injury. Why get an IME if it's not going to be preceded/set up with an effective cover letter?
These 8 approaches are not the only ways to control medical costs in your workers compensation claims. There are various other techniques that can be used to limit medical costs and additional approaches are being developed as more and more employers look for ways to control these costs.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See for more information. Contact: or 860-553-6604.
ABC's of Workers Compensation Cost Containment Book:
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

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