Reduce Your Workers Comp Costs
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
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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: Info@ReduceYourWorkersComp.com.
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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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
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MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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: Info@ReduceYourWorkersComp.com.
Employers are continually searching for ways to reduce workers compensation costs. Triage, where a nurse immediately assesses the employee's medical condition and in some cases arranges for the medical care, is growing rapidly as one of the most effective ways employers can control workers comp cost. In triage, the nurse is involved at the very beginning of the claim. The triage nurse evaluates what medical care is needed through a phone call with the injured employee at the time of injury, provides a list of approved in-network doctors or medical clinics, then passes the claim to a nurse case manager who follows through with the medical provider, the employee, and the employer to ensure the needs of each are met. Companies using nurse triage consistently have very high "penetration rates" meaning that a very high percentage of employees utilize in-network providers; penetration rates for companies using nurse triage are frequently higher than 90%, many approaching 100%.
The triage nurse does not stop after directing the employee to the medical facility. The triage nurse can then contact the medical facility to inform them the patient will arrive soon. Or, this can be done by the employer's workers compensation coordinator. The triage nurse provides the medical facility with the information on the employee’s injury along with the employee’s name, address, phone number, date of birth, social security number, employer's name, address, phone number, and contact information. The triage nurse will also provide the medical provider with billing information and adjuster contact information. Reports of daily activity is sent to the carrier/TPA and the employer, if requested.
Nurse triage makes sure the employee gets to the correct LEVEL of care, but the nurse case manager takes over to "manage" care. Note: When triage is too closely integrated into managing care, it looses focus on preventing unnecessary claims and guiding injuries to the right level of care.
Nurse triage is the process of having an experienced nurse evaluate an employee’s medical needs and direct medical care by determining the appropriate level needed. Employers who do not have their own on-site medical clinic are turning to nurse triage as a means of controlling and impacting workers compensation cost.
Nurse triage companies operate a call center where experienced, trained nurses are available on a 24/7/365 basis. Also, employers who do not staff their on-site medical clinic during all shifts are using nurse triage to cover their employee’s medical needs when their clinic is not open. (WCxKit)
When an employee is injured on the job, the employee and/or supervisor reports the accident direct to the nurse triage company where a trained nurse talks with the employee. The nurse, using proven interviewing techniques, listens carefully to the employee’s description of the accident. He or she asks detailed questions and focuses on the employee’s medical needs. By using treatment protocols and sophisticated medical software, the triage nurse is able to provide an injury assessment. Based on the triage nurse’s assessment of the severity of the injury, the most appropriate level of care and the proper course of treatment can be determined. Then, a decision is made as to where the employee should be sent for medical care.
If the medical care cannot be provided by the employer’s on-site medical clinic or by administering first aid on-site, the triage nurse refers the employee to a preferred medical provider in their network (set up in advance) best suited to provide the medical care needed. By directing the employee to the most appropriate level of medical care, optimum medical care is provided sooner. This also eliminates expensive emergency room visits and prevents the employee from starting medical treatment with a medical provider only to be transferred to a different medical provider later.
1- A key benefit of using nurse triage is the transfer of making initial medical decisions from the employee’s supervisor to a trained medical professional. The employee’s supervisor may discourage the employee from having the needed medical care, as the supervisor wants the employee at work, or the supervisor will send the employee to a medical provider not best suited to treat the employee’s injury. Triage nurses are experienced RNs with recent clinical experience who are specially trained to do this job, and the training centers are impressive. I have toured Medcor’s training facility which is state of the art.
2- The nurse triage will notify the medical provider of the employee’s injury and advise the medical provider to expect the employee’s arrival. This is immediately followed by the claim being reported to all appropriate entities including the risk management department, safety, human resources and the work comp claims office. By addressing the injury immediately with the employee, the employer and insurer have the greatest chance of influencing the cost and overall outcome of the claim. If arrangements have been made with the nurse triage company, they can gather all the information needed and file the first report of injury with the claims office and the appropriate state government entity.
3- Nurse triage can also assist with early return-to-work programs by obtaining an employee’s job description and providing the job description to the medical provider. When the medical provider indicates light duty restrictions instead of returning to work full duty, the triage nurse will contact the employer with the details of the light duty restrictions. A timely determination is made on the employer being able to accommodate the restrictions and place the employee back on the job.
4- A triage nurse’s immediate involvement in a workers compensation claim shows all employees their physical well being is important to the company. The leads to a higher level of morale and trust in the employer. It also provides a big benefit for the employer – bottom line savings on the cost of their workers compensation – as the benefits of nurse triage greatly outweighs the cost for the employer. The nurse triage company can provide your company a cost benefit analysis that will show you the savings generated from using a nurse triage company.(WCxKit)
5- Nurse triage provides a way for the employer to be proactive in the management of workers compensation claims while at the same time being compassionate to the employee’s injury and needs. During a recent assessment of 20 locations of a trucking company using nurse triage, we found that the immediate conversation with the nurses turned many potential lost time claims into either med only claims or “self-care” claims where the employee could ice the injury, for example, and remain at work with his or her ankle inclined.
To learn more about nurse triage and other services, please find sources in our Directory.
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 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 www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Our WORKERS COMP BOOK: www.WCManual.com
WORK COMP CALCULATOR: www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
WC GROUP: 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 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 Info@ReduceYourWorkersComp.com.
A national nursing assistant survey yielded some interesting findings as seen on the Health Care Management Review website. Brought to our attention by Jennifer Christian, M.D., the study tells that nursing assistants (NAs) are an important human resource in health care. They provide direct care to more than 1.5 million nursing home patients in about 16,100 nursing home settings according to the Centers for Disease Control and Prevention. A higher turnover rate in the field (about 66 percent in 2007) among NAs may be linked to reduced quality of patient care in nursing homes, according to the study.
Naturally, workplace injury is a serious concern among NAs, the study states. Transformational leadership (TL) has long been popular among management scholars and health services researchers, but no research studies have empirically tested the association of TL with workplace injuries and absenteeism among nursing assistants (NAs).(WCxKit)
The cross-sectional study explores whether TL is associated with workplace injuries and absenteeism among NAs. They analyzed the 2004 National Nursing Assistant Survey data. A multivariate logistic regression analysis was performed to test the role of TL in the context of workplace performances and results revealed the TL model was positively linked to workplace injury in the level of NAs. Injury-related absenteeism was also associated with the TL style, indicating that TL behaviors may help address workplace absence among NAs.
Findings suggest introducing TL practices may benefit NAs in improving workplace performances.
Over the past 10-year period (1995-2004), about 800,000 nursing, psychiatric, and home health aides were injured in the workplace, the report says. Over the same period, 154 workers in the occupation were killed on the job. Nursing aides, orderlies, and attendants experience the third highest number of injuries and illness, exceeded only by truck drivers and laborers and material movers. (WCxKit)
In a prospective study investigating workplace injuries among NAs in Washington State, revealed that about 46 percent of the sampled respondents reported back and shoulder injuries. The study was based on a national survey and reports that more than half of certified NAs had at least one work-related injury in the past year. Prior studies have suggested that occupational injury may be blamed for the attrition rate of NAs.
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 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 www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Our WORKERS COMP BOOK: www.WCManual.com
WORK COMP CALCULATOR: www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
WC GROUP: 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 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 Info@ReduceYourWorkersComp.com.
In past articles, you have read about the wrong times to use Nurse Case Management (NCM) and other tools that adjusters have at their disposal. Remember, all of these services are not bad to use; in fact, I highly recommend them. They need to be utilized correctly for optimal impact on the file. Senior nurse reviewers are one type of nurse that can be used on ALL claims; the senior nurse reviewers manage the medical portion of the claim and are very effective.
Find out what is being diagnosed, what the exact treatment plan is, what the backup plan is, if the doctor is thinking about referring to an orthopedic surgeon for an evaluation, etc. All of those reasons show the treating doctor you are not going to stand idly by while the patient comes back every 30 days after numerous failed attempts at conservative treatment. This shows you are being proactive on the file. You want to know what is going on so the file can be handled, forecasted, an appropriately reserved. For employers who stay on top of things, their Work Ability Form will contain this information and it will be obtained on the very first medical visit.
Some surgeons are “known cutters,” meaning if a person comes to them for an evaluation, they recommend surgery even when surgery may not be the only option for treatment. Knowledge provided by the NCM can help your and your claimant know issues specific to that office ahead of time, before receiving a surprising report.
In claimant’s mind, talking to a nurse, knowing the nurse will answer any questions, takes a weight off a person’s mind when going through the early claim process. Adjusters must remember workers do not get hurt all the time, and some are scared and have no idea what the future holds. An injured worker worries about bills, money, health, and returning to work. Discussing health issues with the NCM leads to psychological wellness and faster physical healing.
Regardless of the cause, the tears, spurs, and any other damage will be repaired via the surgery your employee may not have gone in for if it weren’t for the workplace injury. The hardest part about a case like this is knowing what to cover under workers comp, and what not to cover especially regarding ongoing disability and workers comp wage loss payments.
When would the claimant recover from the fracture if the other damage was not there? What is your company’s obligation for rehabilitating the employee when you cannot distinguish between the original injury and the on-going issues healing? A NCM can work with the doctor’s office on trying to clarify this. You do not want to pay wage loss or ongoing medical benefits for something that is not your responsibility. An IME can also address this but it is worth asking a NCM first, which may prevent the costs of an IME.
Finally, NCM and MD Guidelines are useful tools an adjuster has to help with claims, and when properly utilized they can be a crucial asset to handling a claim. As long as they are being used effectively, they should be utilized as often as they are needed.
NOTE: The Utilization Review Accreditation Commission (URAC) is an umbrella organization responsible for certifying Nurse Case Managers (NCM); Triage Nurses (TN); Telephonic Case Management (TCM); Field Case Management (FCM); Utilization Management/Utilization Review (UM/UR); and Peer-to-Peer Review. To maintain quality control use vendors which are URAC certified. URAC has stringent protocols for education, credentials, and training for these services.
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 www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Our WC Manual: http://corner.advisen.com/partners_wctoolkit_book.html
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 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 Info@ReduceYourWorkersComp.com.
Keep in mind though that even though it does not influence the outcome of the claim, it may be very useful to build internal management commitment for your program or be a deterrent to fraud when others in the facility become aware that extent of injuries is verified via surveillance. In fact, we at Workers Comp Resource Center are huge proponents of using surveillance to verify the extent of any injury before a settlement is offered. When one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorizing payment of a settlement. LowerWC.com is a stickler for detail.
Consider on a larger scale the costs going into a basic, lost time claim. It is a good bet some of these costs can be eliminated with a more proactive adjuster who is open to getting the injured worker back to the employer by strengthening the adjuster/employer/worker relationship. Knowing your vendors, selecting your own vendors or becoming VERY WELL acquainted with TPA vendors, and specifying the triggers for use in your account instructions, can go a long way toward making your program more efficient.
Medical management in workers compensation is the use of claim handling techniques to control the employees medical care and the associated cost for medical treatment and disability. Normally a nurse case manager (NCM) is employed to coordinate the medical treatment of the employee. Medical management also includes the review of medical care to determine the medical necessity of the treatment and the causal relationship of the treatment to the injury being claimed.
Medical management has become a major part of workers compensation claims because the attending physicians feel more comfortable working with a nurse than they do with a work comp adjuster. The adjuster may not be schooled in traumatic injury where as almost all nurse case managers have actively practiced as RN’s for at least 3 years. Therefore, the adjuster may lack the ability to converse with a doctor in an intelligent manner. The adjuster may also fail to recognize the underlying pathologies that could impact the claim adversely. However, turning the medical management over to a NCM does not relieve the adjuster of the responsibility for medical monitoring of the claim. The NCM and the adjuster should operate as a team. The NCM should always be in contact with the employer and the adjuster after each doctors visit or contact with employee. (WCxKit)
When the NCM is an employee of the insurer or the third party administrator handling the claim, the NCM can enter his/her activity notes directly into the adjusters claim file. When the NCM is a separate vendor, the NCM should be granted limited access to the adjusters files note for the purpose of documenting the medical management activities as they occur.
The NCM generally consults with the treating physician during the medical treatment period and will attend the medical appointments with the employee. This will give the NCM insight into the employee that the adjuster may never be aware of otherwise.
The NCM should be employed as soon as the claim appears to warrant it. Depending upon the severity of the injury, the NCM may be needed immediately, or they may not be required until the employees medical recovery is unusually long. Also, a NCM maybe employed when some underlying medical issues occur or medical care not related to the injury begins to appear in the claim.
The goal of medical management is to return the employee to gainful employment through appropriate treatment in a timely manner. This will minimize the lost time and disability. The NCM will be instrumental in arranging transitional duty jobs suitable for the disability during the recovery process.
It is imperative that the NCM have a full job description, and in some situations, actually see the job in operation. This will give the NCM the ability to properly discuss the case with the treating physician. If necessary, the NCM should obtain a video of the employees job operation and provide it to the treating physician. It will assist the NCM in obtaining the treating physicians consent for the employee to return to his old job. If modifications or changes in the employees job are needed for the employee to be able to do his job, the NCM will work with the employer to accommodate the employees limitations.
The work comp adjuster also has a role in medical management. The adjuster should verify the employee is not working and can not work due to the medical disability. Before issuing payment of temporary total disability benefits, the adjuster should verify the employee is pursuing curative treatment. The adjuster can do this with direct contact with the employer, the employee, the NCM and the treating physician.
A mistake often made by the adjuster is to place the claim on automatic payment of disability benefits without maintaining regular contact with the employer, employee and NCM. The adjuster should always be knowledgeable of the employees medical condition and the level of activity the treating physician will allow the employee. Without the adjuster involvement, if the claim is on automatic payment of disability benefits, overpayment of benefits will likely occur. If the employee does not later have a claim for permanent disability benefits, the overpayment of temporary disability benefits will be difficult to recover.
In approximately half of the jurisdictions, the employee is given the option of selecting his own attending physician. Often this is not a problem. However, some plaintiff attorney friendly physicians may have a tendency to extend the disability period more than normal. Or, they may begin to treat non-injury related medical problems of the employee. In these situations, it is essential for a NCM to be assigned to the claim.
If the injury is severe or if the recovery time is longer than normal, an independent medical examination (IME) should be considered. The doctor who will perform the IME should be provided a complete copy of the medical records and a full description of the employees job. The IME doctor should never have to rely on the employee for information about the job. The results of the IME will provide the NCM and the adjuster with valuable information for claim management and disposition.
As some jurisdictions impose time limits on when the IME can be performed and imposed restrictions on the number of IMEs that can be completed, the NCM in conjunction with the adjuster should determine the most opportune time for the IME.
A separate area of medical management is the reviewing of the physician’s bills for proper charges and the need for the care provided. Almost all companies reviewing medical bills for accuracy are now using computers to do the bill reviews. In the states where usual and customary fees are used, the medical bill review will compare the fee schedule to the provider’s bill in order to determine the appropriateness of the billed fees.
A NCM through medical management can bring about a reduction in the amount of time the employee is disabled and have an impact on the medical treatment cost. However, the adjuster needs to be vigilant in managing the NCM. Normally, the NCM is billing an hourly fee plus expenses. The adjuster needs to reviews the billing and the medical status of the employee to verify there is an on-going need for the NCM services. At such point the cost of the NCM begins to equal the savings on the claim, the NCM should be released from further responsibility on the claim. (WCxKit)
Medical management when properly used will lower the cost of the work comp claims. The employer should verify the adjuster is using all medical management techniques noted above.
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.
Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
WC IQ TEST: http://www.workerscompkit.com/intro/
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 or agent about workers comp issues.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Success Story: A large transportation company thought their claims were not handled aggressively enough and poorly performing adjusters were driving workers up comp costs. The dissatisfaction had grown to such proportions that they put the business out to bid. They did, in fact, change TPAs.
Resolution: One MD and one senior claim analyst reviewed 20 claims in each of three offices (TX, CA and MA) and found there was a problem with the MA office. The adjuster handling their claims in that office was inexperienced and disorganized. There were administrative quality issues such as lack of supervisor oversight, insufficient investigation, untimely 3-point contact, no recorded statements being taken, and claimants were being overpaid because the “average weekly wage” was miscalculated. IME’s were overused and medical causality was not established prior to claim payment. Pre-existing conditions were not recognized by the adjusters or nurses resulting in higher than necessary reserves. Nurse case management was being brought in too late to be effective. The client, however, thought the NCM was “too expensive” but the problem was really that it needed to be brought in earlier.
We set up new triggers so when an employee does not return to work within 2 days a nurse case manager is immediately assigned. The TPA enhanced their training program to ensure nurses were reviewing files for pre-existing conditions and completeness of medical records. The employer retained a part-time medical director to review claims if an employee had not returned to work within two weeks. IME’s were not requested until the medical director reviewed the file, insured complete medical records were obtained and crafted a custom letter requesting specific medical information.
The employer had insufficient staff to monitor or manage the TPA; there were 3,000 claims annually at over 500 locations with only one person, who was not an actual risk manager, assigned to workers compensation. We suggested the company hire a risk manager and select eleven people (one for each region) to serve as WC Managers (WCM) which was quickly done. Onsite training was done for the new WCMs. The TPA participated in the training to meet the WCMs then did a “national rollout” providing new “panel cards” so employees could select network physicians. The TPA met with each location to open communication channels.
We met with the client, TPA and broker on weekly conference calls for the next 52 weeks until all suggestions had been implemented. To keep team members accountable, we sent an “Implementation Action Plan” to each participant following the conference call.
Result: Losses down 25% for past 3 years and continuing.
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. Contact: RShafer@ReduceYourWorkersComp.com
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 or agent about workers comp issues.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
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