The Best Tidbits of News from the Workers Comp Community

 

 
In The Washington Post's On Small Business Blog, MCA's Director of Nurse Case Management, Barbara DeGray, discusses techniques for overcoming feelings of isolation for remote employees. Read more…
 
 
 
Longtime insurance technology executive Mark Stergio has been named CEO and senior vice president of risk management information systems (RMIS) provider Risk Sciences Group (RSG, Atlanta). He will be responsible for continuing the development of a long-term strategy for RSG that focuses on innovative technology, effective analytics and easy-to-use applications that help clients control their overall cost of risk, according to the company.  Read more…
 
 
 
MSP & MIR Program Featured at This Year's  
Worker's Compensation Conference   
 
Bret Cade, Executive Vice President of Sales & Marketing at Gould & Lamb, will be the featured moderator for the 2012 WCI Conferences' full-day program titled "Providing Clarity in a Land of Confusion".  This comprehensive breakout, sponsored by Gould & Lamb, will seek to clarify what has become an extremely complicated process, creating enormous issues for the workers' compensation industry, soon to further expand into the general liability area.  Conference Homepage
 
 
 
Lexis Nexis Lays out Blueprint for HIPAA & ADA Compliant Wellness Programs   
 
 
“Blueprint for HIPAA and ADA Compliant Wellness Programs: Encouraging Good Health Reduces Workers' Compensation Expenses, by John Stahl, Esq. The article "Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based Incentives" in the Journal of Occupational and Environmental Medicine demonstrates how employer-sponsored outcomes-based wellness programs (wellness programs) reduce workers' compensation and other employment-related healthcare costs.” Read more.
 
 
“Court Dismisses Injured Worker's Tort Action Against Carrier for Five-Month Delay in Medical Benefits, by Thomas A. Robinson. A Texas appellate court recently affirmed the dismissal of a tort claim filed against a workers' compensation carrier, another defendant (Southwest) that had provided administrative services, and a physician alleging that the trio were liable for damages under common-law bad faith, statutory bad faith, and fraud theories associated with the carrier's delay of five months in paying benefits to the plaintiff-worker. Read more about this case and other cases involving incarceration, borrowing employer, and causation of injury.”
 
 
“Workers' Comp, Texas Style: A Highly Regulated System in a Pro-Business State, by Stuart D. Colburn and Albert Betts, Jr. Cotton, cattle and oil were the primary economic engines when Texas first adopted workers' compensation. In the 100+ years since, the economy and workers' compensation laws have changed dramatically. The shift from an agricultural to a manufacturing and then to an information based economy changes the frequency and type of injuries sustained at work. Health insurance, Medicare/Medicaid, and disability insurance alter the landscape of both a social safety net for employees and higher costs for employers.” Read more.
 
 

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

 

 


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How Nurse Triage and Nurse Case Management Work Together to Reduce Workers Compensation Costs

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%.
 

 
Triage in workers compensation is a concept that has been borrowed from hospital emergency rooms where the triage nurse is responsible for immediate assessment of the individual's injury and organizing the treatment based on the seriousness of the injury. In workers compensation, the triage nurse immediately evaluates the nature and type of the employee’s injury and directs the employee to the proper level of medical care whether it is first-aid, a walk-in clinic, or an urgent care facility. Sometimes the employee is given home-care instructions. (WCxKit)
 
 
The proper use of triage eliminates lag time and indecision. The injured employee, the employee’s supervisor or a co-worker (in an emergency situation) can report the occurrence of the injury to the triage nurse by phone. Most triage organizations provide a toll-free “hot-line” number for workers compensation claims to be reported and are staffed 24/7. The triage nurses that answer the calls are trained to obtain all necessary information in order to perform a comprehensive evaluation of the medical needs of the injured employee. The triage nurse will use treatment protocols and algorithms to identify the proper course of treatment. The employee is then directed to the nearest appropriate level medical facility. These nurses are specially trained and have had a minimum of 10 years of clinical experience.
 
 

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. 

 
Note: The triage system is more likely to refer more often when the triage provider gains economically from opening a claim. Even "features" that seem convenient like 800 numbers and aps that  make it easy for employees to find networks clinics themselves result in employees bypassing triage and going straight to the clinics.  

 
After the employee has had time to be treated, the case managment nurse will contact the medical facility the same day and determine the nature of the medical treatment. Sometimes, this can be done by a senior nurse reviewer or the employer's medical director. A senior nurse reviewer is a nurse who reviews and follows ALL claims from beginning to end; they monitor all claims within an insureds book of claims. A nurse case manager will inquire to see if there are any prescriptions that need to be filled, if there is any diagnostic testing (MRI, CT scan, EMG, etc.) that needs to be done, and if there is a need for durable medical equipment. The case management nurse will then advise the workers compensation adjuster of the prescriptions, diagnostic testing, and durable medical equipment that is needed. Once the adjuster approves the requested prescriptions, testing or equipment, the case management nurse will assist in arranging for it.
 
 
The case management nurse will also ask the medical facility for the return-to-work restrictions placed on the employee by the medical provider. If the employee can return to work with restrictions, the case management nurse obtains all the information on the work restrictions and contacts the employer to see if the employer can accommodate the return-to-work restrictions. IF the employer has a return to work coordinator, the return to work coordinator can make contacts related to transitional duty capabilities.
 
 
The recommendations of the medical facility for future medical care and the date the employee will be returning to the medical provider will be obtained by the case management nurse. If the employee needs diagnostic testing prior to the return appointment being scheduled, the case management nurse can follow up with the medical facility providing the diagnostic testing and provide the test results to the medical provider. 
 
 
The case management nurse (NCM) will facilitate and expedite the communication between the medical provider, the employer, and the workers comp adjuster. NCM also has the responsibility of keeping everyone informed about the medical status of the employee. The NCM will be in regular contact with the employee, the employer, the medical provider(s), and the workers comp adjuster. All information about the medical treatment, medical progress and return-to-work options are shared with all parties.
 
 
The length of time the triage nurse will continue to work on the new workers claim is determined by the arrangement between the employer and the triage company but generally the triage nurse will hand the case to the case management nurse once the initial care is evaluated. The case management nurse will normally continue on the case until the employee returns to work full time however there may be a need for a nurse case manager depending on the severity of the injury or the employee's inability to return to work even in a modified duty capacity. (WCxKit)
 
 
Integrating the triage nurse into the initial medical treatment allows the employer or insurer to set the tone and level of medical care and ensure the employee gets the appropriate level of care immediately. Then the nurse case manager helps to coordinate employee's return to work before the employee has the opportunity to adjust to the idea of not working. By providing medical management at the beginning of the workers comp claim, the triage process improves the return-to-work program results, reduces days lost from work, lowers the cost of indemnity payments, and lowers the cost of medical care. Normally, nurse triage can reduce the number of lost time claims by up to 40%. 
 
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. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.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.
 
©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.

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 www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
 
 
ABC's of Workers Compensation Cost Containment Book: www.WCManual.com
 
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.

Workers Compensation Medical Management Techniques

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.
 

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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.


©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

 

Getting the Best Initial Care for Your Injured Workers

As an employer, you want your injured employees to get the best care available when they are hurt. You also want to find healthcare providers who understand your company’s specific goals, needs, and possibilities. And you want them focused on the bottom line as well.  A very tricky balancing act –  but a necessary one!

 

 

How can you locate and identify a good initial healthcare provider? Here are a couple of suggestions from a case management nurse who has been around the block a few (million!) times: (WCxKit)

 

 

  1. For your initial evaluation and treatment, a great choice is an experienced Occupational and Environmental Health Physician (OEM). This is a specialty of physicians who evaluate the interaction between work and health. An Occupational Health doctor should be familiar with work operations, return to work procedures, workers compensation laws in your jurisdiction, and many other related topics.   Please note:Just because the local clinic calls itself an “Occupational Health Clinic” don’t assume the doctors are Occupational and Environmental Medicine Physicians!

 

 

  1. As you are selectingor reviewing your panel provider for occupational health, CALL the center and speak to the administrator. Set up a tour. Meet with the doctor(s). Ask about their specialty and experience. You are putting your employees’ health and your money into their hands, so go and check them out. Trust me — if the doctors won’t play nice with you, they certainly won’t play nice with your injured workers.

 

 

  1. If you’re not sure where to find a qualified OEM doctor, check out the website for the American College of Occupational and Environmental Medicine, www.acoem.organd click on “Find a Doctor.”

 

 

  1. If you are in a locationwhere there is no qualified OEM nearby, talk with your nearest occupational health center’s medical director and make sure he or she is familiar with your state workers compensation laws, your company’s policies regarding post-injury care and return-to-work, and that the doctor is willing to keep in close contact with you during treatment of your injured employee. Feel free to send over your own post-accident form for the doctor to complete, if you don’t like the form the center provides. You’re paying for this service – make it work for you!

 

 

  1. PAs and NPs and DOs, oh my!Yes, there are too many initials in medicine. Let’s see try to clear up some you might encounter at your Occupational Health Center.

 

 

PA = Physician Assistant

A PA has completed an educational program lasting approximately 26 months; is state-licensed and certified by examination, and must complete continuing education regularly. A PA can prescribe medications, and must work under the supervision of a physician.

 

 

NP = Nurse Practitioner

An NP has completed graduate education as a Nurse Practitioner beyond the Registered Nurse program, either to the master or doctorate degree level; is state-licensed and nationally certified by examination, and must complete regular continuing education. A NP can prescribe medications and, depending on the regulations of their state may or may not function under a physician’s direction. Some states allow NPs to set up private practices without physician supervision. Other states require some collaborative agreement with a physician. (State Requirements)

 

 

DO = Doctor of Osteopathy

Yes, they are “real doctors.” To generalize greatly, DOs have the same scope of practice as MDs, though there are differences in their training and treatment techniques. DOs are licensed to practice the full scope of medicine throughout the United States.

 

 

Overall, we recommend good old fashion COMMUNICATION! If you or a supervisor, adjuster, or case manager isn’t comfortable calling your healthcare provider to touch base about a tricky case, then you’re using the wrong facility. (WCxKit)

 

 

Remember, if you are in a Employer-Choice or Panel state, this is YOUR CHOICE. Make an informed decision. Be comfortable with your choice. If you’re in an Employee-Choice state, it’s still a good idea to have an Occupational Health center you are comfortable with and use.   Often, you’ll end up sending your injured worker there, at least for an initial evaluation and quick treatment.

 

 

Starting with the best possible healthcare provider gets your claim off on the right foot (or shoulder, back, knee . . .). Do your homework and you’ll be ready!

 

 

Author: Kelly Haile, RN, CCM, WCCM is an experienced Nurse Case Manager who advocates working closely with each employer to refine their Workers Comp program to provide better post-injury care, excellent medical case management and timely communication. We provide services primarily in the PA, NJ, DE and MD areas.  You can reach Kelly in her role as Director of Case Management at NursePartners, LLC, by phone at 610-323-9800, fax 610-323-8018, Email: khaile@nptrs.com.


WORK COMP CALCULATOR:   
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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.

 

TPA and Insurance Carrier Roles For Dummies

If you think all the claims people are located in the claims office, you would be in the large majority of the risk and insurance world, and you would be wrong. There are various types of claims people in support and management roles at the insurers and the third party administrators (TPA) who have a major impact on the success of your workers’ compensation program. Here is a brief synopsis of the other claims people you may never hear about.

 

Account Administrator/Risk Technical Adviser

This position was previously known as the “home office examiner,” but insurance companies and TPAs have renamed the claims position in several different ways. In some companies it will still be referred to as the “home office examiner,” but other names like “account administrator” and “risk technical adviser” are being used to describe the position.

 

The home office examiner/account administrator/risk technical adviser is a person with a tremendous amount of claims knowledge, claims experience and “know how” who oversees the catastrophic injury claims — the more difficult and expensive claims. The home office examiner’s role is to be a “second set of eyes” on the file. The home office examiner will review the catastrophic injury claims to be sure the medical management, disability management and resolution of the file is handled in the best interest of the insured and the insurance company. (WCxKitz)

 

The home office examiner will provide direction and supervision whenever the claims office asks for guidance. The home office examiner will also intervene if the course of the claim is not what it should be. At TPA’s this role will also encompass verifying the claim offices are complying with all the requirements of the client.

 

Account Manager

The account manager for the insurance company, or the TPA, is a hybrid role between a claims person and a salesperson. The account manager acts as a liaison between the employer, the insurer and the TPA, when a TPA is handling the claims.

 

Often the account manager is a direct contact for the employer’s risk manager or claims coordinator with the intent of resolving all insurance program related problems and answering all questions about the insurance program. The account manager is the go-to person to resolve any issues that arise whether it is compliance by the claims office with the service standards, the deletion or adding of new locations to the insurance program, the resolution of questions about the program or the corrections of any errors or mistakes in the data management.

 

Nurse Case Manager

The role of the nurse case manager is to provide medical expertise beyond the knowledge the adjuster will acquire from reviewing medical reports and medical histories. The nurse case manager is a license practical nurse or a registered nurse who has the nursing degree plus years of experience in the medical field. (WCxKitz)

 

When the nature of the injury is severe and the adjuster wants medical management of the claim to be provided, the nurse case manager is assigned to the claim file. The nurse case manager will coordinate and facilitate the health care services provided to the injured employee to assist the employee in achieving the best recovery possible.

 

The nurse case manager will provide to the adjuster a patient assessment and a treatment plan that has been coordinated with the medical provider. The implementation of the treatment plan and the execution of the treatment plan are part of the nurse case manager‘s responsibilities.

 

Not only is the nurse case manager an adviser to the adjuster but also a trained medical expert who can answer the medical questions the injured employee may have between medical provider visits.

 

Adjuster-in-charge

The adjuster-in-charge, also known as a “resident adjuster,” is often used when a large employer wants an on-site adjuster to handle their workers’ comp claims. This facilitates the immediate reporting and the immediate investigation and handling of each new injury claim. The adjuster-in-charge is an employee of the insurer or TPA, but is domiciled at the employer’s location or in a one-person office near the employer.

 

The adjuster-in-charge will be an experienced adjuster who is capable of working independently from an on-site supervisor. The workload of an adjuster-in-charge will normally include a mix bag of simple workers’ comp claims to the most severe claims. The position often entails the adjuster having to do everything from taking in the new assignments to the closing of the claim files. (WCxKitz)

 

Regional Manager

When an insurer or TPA has a large number of claims offices, the supervision of those claims office is often broken down into regions of the country. The regional manager is responsible for the services provided by the claims offices in the territory or region.   The regional manager provides the direction to the claims offices and provides the home office management with a greater degree of control.

 

Vice President of Claim

At the top of the claims hierarchy is the vice president of claims. The responsibilities of the vice president of claims includes the planning, organizing, directing and controlling of all the activities of the claims offices and claims regions. The vice president of claims is also responsible for the performance of the claims offices, the profitability of the claims offices and the claim services provided. (WCxKitz)

 

Summary

The various support roles outside of the workers’ comp claims office are often the keys to the success of the claims program. Whether it is the claims examiner keeping the high dollar files on track, the account manager resolving all the issues that come up, the nurse case manager providing the necessary medical expertise or the senior management overseeing the claims program, they all can have a positive influence on making your workers’ comp insurance program successful.

 

 

Author Rebecca Shafer, J.D, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com .

WC Calculator:  http://www.LowerWC.com/calculator.php
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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.


©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

 

Chronic Pain Management Causes Long and Costly Payouts

In a recent claims audit of workers’ compensation claims for a Texas municipal pool, the claims auditor was astonished by the number of lifetime medical claims.  The indemnity benefits had been paid out, sometimes years ago, but the former employees were still treating on a regular basis.  In most of the claims the reason the employee had been seeing the medical provider for years was due to chronic pain.

 

Chronic pain refers to the medical condition where the injured party continues to suffer pain from the injury six or more months after the injury occurred and the pain is not relieved by medical or surgical care.  For the treating physician, a patient’s chronic pain and the management of it can be a difficult process.  Chronic pain can be hard to detect which makes it a difficult diagnosis for the physician.

 

The condition of chronic pain can continue for years or even the lifetime of the employee.  In some cases the injured employee can return to work with the pain and ‘live with it.’   However, often the pain can be severe enough to be debilitating, preventing the injured employee from returning to work.

 

Chronic pain is often associated with Reflex Sympathetic Disorder (RSD) but can be present without RSD.  When an employee develops RSD pain is often describe as a severe burning pain.  While pain is very difficult to measure, there are physical symptoms of RSD the physician can see and measure including skin temperature changes (warmer or cooler than other parts of the body), skin color changes, stiffness and swelling in affected limbs, and decreased ability to move an affected extremity.

 

It is the work comp claims where the employee develops chronic pain without a RSD diagnosis that create a difficult situation for the work comp adjuster.  Chronic pain can develop from various types of injuries including herniated and/or ruptured disc, amputation of a body part, joint injuries like carpal tunnel syndrome, torn ligaments and torn cartilage injuries and even traumatic brain injuries.

 

As chronic pain cannot be seen and is very difficult to measure, it is sometimes used as an excuse to stay off work by unscrupulous employees.  The employee, who had a valid injury,  becomes adjusted to receiving compensation without working and finds the claim of chronic pain to be the path to long-term benefits.  The adjuster becomes suspicious of the employee’s delayed recovery due to chronic pain, sends out surveillance and finds the employee playing golf or performing strenuous work (away from the job).   It is these fraudulent claims that give chronic pain a negative connotation.

 

Of course there are many totally legitimate injury claims with chronic pain. The challenge for the adjuster then becomes separating the valid chronic pain claims from the bogus claims, and then providing chronic pain management for those employees who truly need it.

 

Usually the first step the work comp adjuster takes to verify the employee’s chronic pain is to have an independent medical examination (IME).  In some situations the IME doctor can verify the existence of chronic pain, but often the IME doctor cannot state with certainty whether or not the employee has a chronic pain condition.

 

After the IME, the next step for the adjuster is often to have a nurse case manager (NCM) assigned to the chronic pain claim, if a NCM has not already been working with the employee.  Chronic pain management can become very expensive and take a considerable amount of medical knowledge to properly control.  The NCM can discuss with the treating physician and the employee the best course of chronic pain management.  The NCM should remain involved in the chronic pain claim until the employee is able to return to work or it is determined the employee will never return to work.

 

In most claims the treating physician initiates the use of pain medications, usually opioids (narcotics), to control the chronic pain.   There are several problems with using opioids to control pain.  The first one faced by the treating physician is to established the proper dosage for the employee.  If the dosage is too low, the employee continues to suffer the pain.  If the dosage is too high, the employee can become addicted to the pain medication.

 

Addiction is a problem with opioids for chronic pain management.  The employee who started taking the opioids for the chronic pain likes ‘feeling no pain’ and become addicted to the opioids.  With the addiction the employee becomes accustomed to having the narcotics in his body, and to continue to achieve the same effect, the dosage has to be increased.  This leads to dependency on the drugs.  It also creates withdrawal symptoms when the opioids are reduced or stopped.

 

The NCM must work with the physician to go beyond the use of narcotics to control the chronic pain.  Instead of the narcotics the physician may consider electrotherapy with a transcutaneous electrical nerve stimulation (TENS) unit.  Similar in effect to the TENS unit are pain pacemakers that can be implanted in the body to deliver low-level electrical stimulation to the spinal cord.

 

Another method to control chronic pain is the use of trigger point injections.  A local anesthetic sometime with a steroid is injected into the painful area to relieve the pain.  In some cases in only takes a few injections to resolve the chronic pain.  Trigger point injections are often combined with physical therapy to recondition the muscles while the pain is being alleviated.

 

In the last few years some doctors have turned to anticonvulsants to control chronic pain. How anticonvulsants reduce pain is unclear but appears to be effective in some types of chronic pain control.  Another recent approach being used to control pain is low dosage antidepressants which influence the level of certain chemicals in the brain.

 

Also, as there appears to be a mind-body connection when it comes to chronic pain, alternative treatments like psychotherapy and relaxation techniques are being tried with some success.

 

A pain management specialist/clinic can be utilized to assist the employee.  The NCM can coordinate the treating physician, the pain management specialist, and any other medical providers including orthopedists, anesthesiologists, psychologists, and physiatrists.  The NCM will review the medical and psychological aspects of the employee’s case with the pain management specialist to determine the best course of action.   (workersxzcompxzkit)

 

Fortunately chronic pain workers’ compensation claims are infrequent, but when they do occur, they tend to be very expensive and can last for years.   Learning how chronic pain claims should be managed will save the insurer or self-insurer significantly on these large dollar claims.  The experienced work comp adjuster working with a dedicated NCM can control these claims for the benefit of both the employer and the employee.

 

Author Rebecca Shafer, J.D., Consultant,  has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at:  RShafer@ ReduceYourWorkersComp.com or 860-553-6604.

Podcast: KNOW the New OSHA Recordkeeping Rules — OR Risk Fines and Criminal Penalties. Click Here:
http://www.workerscompkit.com/gallagher/podcast/Non_Compliance_with_Recordkeeping_Standards/

 

WC Calculator:http://www.reduceyourworkerscomp.com/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.

 

©2009 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 Nurse Case Manager Defines Nurse Case Management and Describes Types of Nurse Case Management

What Exactly Is Case Management Anyway?

Case management  is defined as the collaborative process of assessment planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes. 

From a work comp  viewpoint what does all of this mean to the injured worker and the employer?

1.  When an injured worker  reaches the optimum level of wellness and functional capability everyone benefits.
2.  When a nurse case manager  is involved, days away from work or “lost time” can be reduced without affecting the quality of care.  In fact, care is often enhanced by the expertise that a nurse brings to the case.

Nurses who work
 as case managers in the area of workers’ compensation come from varied backgrounds.  Typically these nurses first worked in occupational health, managed care, and discharge planning before starting with workers’ compensation.  Because so many work injuries are related to orthopedics or neurology, a nurse with expertise in these areas is extremely beneficial.

The Different Type of WorkComp Nurse Case Management

1.  Telephonic- Nurse Contacts  are only by phone or letter.
2.  On-site,  also known as Field Case Management, (this is the most effective form of case managment). Nurse visits the claimant in person at physician appointments, at the worksite, meets with the employer or attends medical visits with the claimant to discuss follow-up care and treatment.
3.  Task-Nurses  are directed to carry out a particular task and are not assigned to the file for an extended period of time.  It might be to collect a report or to prepare records and coordinate for an Independent Medical Evaluation (IME). (workersxzcompxzkit)

Regardless of the type  of case management used, the nurse should be at the center and an ACTIVE contributing member of the team.

Our guest author Victoria Powell is the President of VP Medical Consulting, LLC located in Central Arkansas.  VP Medical Consulting is a nurse consulting firm providing services to employers, insurance companies, attorneys and the general public.  Services include case management, life care planning, legal nurse consulting, ergonomics and patient advocacy.  Ms. Powell holds specialty certifications in a variety of nursing specialties.  She can be reached through the web at
http://www.vp-medical.com or by phone at 501-778-3378.

We are accepting short articles* (300-800 words)
on WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com. *Non-compensable.

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

©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

Interview of Nurse Case Manager Her Perspective on Return to Work

A Nurse Case Manager’s Experience

As a nurse case manager working in workers’ compensation, most of my patients think my questions and recommendations regarding a return to work are just about saving the company money.  While there is a cost-savings with the claimant returning to work, there are also other benefits.

 

Every day I see  depression  related to a prolonged period away from work and the regular work routine.  This is particularly a problem with men.  Men tend to define themselves as “the worker,” the one providing for the family.  There is a  loss of identity  when injured workers can no longer identify themselves by their job.  Financially they suffer.  Their regular routine is disturbed.  Many fail to even dress for the day since they have no place to go.  Throw in the pain of an injury and the frustration with the system and soon you see clinical depression.

 

5 Reasons to Return-to-Work Quickly

  1. Reduced recovery time.  Working light duty or transitional duty helps the body to keep moving.
    2.   Reduced  medical costs.  RTW keeps depression at bay.  It can also prevent costs associated with work hardening programs and the like.
    3.  Improved employer relations.  If a worker is allowed to return they feel valued, while the alterative of sitting at home without contact from the employer can make them feel devalued.
    4.  Transition back into work.  A return to work program allows for a transition to reacquaint the body with the essential job functions and minimizes reinjury. (workersxzcompxzkit)
    5.  Reduces  potential for fraud and abuse-Prevents rewarding the worker financially without the benefit of work.

Author: Victoria Powell is the President of VP Medical Consulting, LLC located in Central Arkansas. VP Medical Consulting is a nurse consulting firm providing services to employers, insurance companies, attorneys and the general public. Services include case management, life care planning, legal nurse consulting, ergonomics and patient advocacy. Ms. Powell holds specialty certifications in a variety of nursing specialties. She can be reached at 501-778-3378 or through the web at http://www.vp-medical.com/

WC Calculator: www.reduceyourworkerscomp.com/calculator.php
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Do not use this information without independent verification.
All state laws vary.

©2008 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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