Improve Your Bottom Line With Nurse Triage

August 29, 2012 by Leave a Comment

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: RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact:  mstack@reduceyourworkerscomp.com. 

 


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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.

 

Filed Under: Medical Cost Containment Tagged With: , , , , , ,

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

January 23, 2012 by Leave a Comment

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.
Filed Under: Claim Management, Medical Cost Containment Tagged With: , , , , , ,

Top Industry Exec Offers Workers Compensation Year-In-Review

January 7, 2012 by Leave a Comment
 
 
Two-thousand-eleven has been an interesting year in the workers compensation industry. New software has helped many administrators take better control of their costs, studies on safety have led to an increase in preventative measures and legal changes have led to unusual and sometimes controversial administration in some states.
 
 
Here at Roundup we asked one of our favorite experts, Curtis Smith, executive vice president of Medcor, Inc., a national on-site health services company, what he thought the top WC issues were for 2011. What follows are his conclusions:
 
Conflicts of Interest Inherent in the Industry
The very organizations employers depend on to help manage and reduce costs depend on claims for their core revenue – and this can lead to potential conflicts of interest, according to Smith. He offers these examples: contingent commissions for brokers and consultants, TPAs (third-party administrators) and MCOs (managed care organizations) who select network providers and share revenue from provider discounts. Smith also cautions against pharmacy chains that put pharmacies on-site in large worksites for convenience also employ the practitioners who write the prescriptions.
 
 
Prescription Drug Abuse
Thousands of people incur illness and injury each year from abuse of prescription medications, especially pain medications. Addictions and overdoses are increasing, as are deaths, Smith wrote. Addictions often arise from treatment after a work-related injuries but the medical community is not policing or restricting doctors who write these prescriptions. What’s more, TPAs are not excluding these unrestricted doctors from networks of approved providers for fear of litigation.
 
 
Prescription Drug Costs
The same medication can cost 10 times as much in workers compensation cases as it does in general health applications. Medications’ fee schedules have been negotiated down and controlled in group healthcare far more than in workers comp situations. Consequently, drug companies and others are moving into the comp space to take advantage of increased profitability, Smith said.
 
 
Increased Litigation in the Industry
The fundamental premise behind the workers compensation system is falling apart in many states (e.g. California and New York) where an increasing percentage of claims are contested and litigated. Huge settlements out of proportion to true economic need are forcing employers to be defensive and deny claims; denying and resisting legitimate claims forces employees to seek counsel and litigate. The comp system is turning into a battleground of plaintiff and defense attorneys working the system.
 
 
Injury Triage
Smith said he would be remiss if he did not mention injury triage. “This truly is an effective way to reduce unnecessary claims and costs, to identify serious cases, and to provide early intervention for all cases,” he wrote. Financial and health outcomes are improved with the use of triage. “It’s also innovative – wining several U.S. patents — are there any other WC methods that have been patented in the last 10 years? Or ever?” he asks. Thousands of companies are using triage and many competitors have joined the market, providing a variety of service and pricing models. Yet, many employers (even most) still don’t use it and the claims-driven industry still resists it.
 
 
Even those who offer injury triage often do so begrudgingly to satisfy their employer-clients, to block another triage provider from taking claims away, or to acquire business – but they are slow to introduce triage to an existing book of businesses, or, once introduced, often let implementation and utilization languish so claims can continue to flow.
 
 
In conclusion, look to hear more about these important topics in 2012. Though they may not be resolved in short order, they are certainly going to be on the minds of those of us in the industry in years to come.
 
Curtis Smith is Executive Vice President of Medcor and can be reached at csmith@medcor.com or 815-363-9500 Ext 5558. Visit Medcor at www.Medcor.com
 
 
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.
 
 
2012 WORKERS COMP MANAGEMENT GUIDEBOOK:  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.
Filed Under: Assessment & Diagnostics, Benchmarking & FTE & Operational Comparison, Fight Workers Comp Fraud & Abuse, Medical Cost Containment, TPA and Claims Administration Tagged With: , , , , , , , , ,

Ten Medical Cost Containment Strategies To Reduce OVERALL Costs

February 22, 2011 by Leave a Comment
There are many available techniques to control medical cost in workers compensation.
 
A search of the internet for Medical Cost Containment will provide a tremendous amount of information but each website is focused on the product(s) or service(s) provided by the particular company. There are many and varied means of controlling medical cost in workers compensation which span a broader range of services than almost any single company can provide.
 
 
To be truly effective in controlling the medical cost of workers compensation, employers and insurers should not limit their medical cost containment efforts to only one or a few areas. While state statutes may limit or bar the use of some the methods of controlling cost, the employer or the insurer should utilize as many medical cost containment strategies as possible. All of the following medical cost containment strategies have been shown to save money for the employer or the insurer. (WCxKit)  Spend now to achieve overall lower workers compensation costs. This is how to hold costs down over the long term. This is referred to as the TLC (total loss costs).
 
 
Top 10 Medical Cost Containment Strategies
 
 
1.  A SUPERIOR Medical Provider Network is a group of doctors, hospitals and other medical providers with whom an insurer or a self-insured employer has prearranged for medical treatment for employees injured on the job AND provides better results than other providers – lower litigation rates, better medical outcome, faster return to work. 
 
 
2. Nurse Triage  is used as the very first phone call that is made (after the supervisor). The employee calls an RN who discusses the severity of the injury and the probably type of treatment that will be needed. These aren’t just any nurse, but specially trained ones using medical algorithms and overseen by sophisticated protocol to ensure appropriate referrals are made the the Emergency Dept, clinical treatment or self-care. If every injury is called in to Nurse Triage, the number of lost time claims will be reduced by 40%. The ROI is huge! I’ve toured the Medcor operation and was amazed at the efficiency and the training (I sat in the training room to view the type of training the RNs receive.) I was a guest of Broadspire who uses Medcor for their sophisticated medical protocol partner.  
 
 
3. Medical Management is the practice of having an experienced nurse case manager to coordinate and managed the medical care received by the employee. This includes both the senior nurse reviewer who may be dedicated to an account handling all lost time or serious medical claims for that company. They review all care and treatment for injured employees to insure it is appropriate and timely. If additional tests are needed they will advise the doctors. Their priority is getting the employee back to full recover.
 
 
4. Utilization Review is the independent confirmation of the need for a medical service. Utilization review includes precertification reviews before the medical care is provided, concurrent reviews while the employee is in the hospital or during on-going medical care, and retrospective reviews to verify the needs for the medical services already provided.
 
 
5. Medical Bill Reviews are normally done by companies that specialize in reviewing the medical bill to verify the accuracy of the medical bill diagnostic codes and medical bill charges. The medical bill charges are either compared to the state fee bill schedule or with what are reasonable and customary charges for the medical services provided. Medical bill reviews include both the audits of doctor bill and hospital bill auditing.
 
 
6. Pharmacy Benefit Managers are companies that specialize in managing and controlling the cost of medications prescribed for the employee. This includes both obtaining discounts on medications plus providing drug utilization reviews to prevent the excessive use of narcotics and other medications. Using physicians to actively review claims results in proactive pharmacy benefits management, rather than after the fact review of medications already taken, can stop overuse before it occurs.
 
 
7. Independent Medical Examinations occur when the employee is sent to another medical provider for a second opinion. Independent medical examinations are most often used when the employee’s medical recovery progress is slower than normal.
 
 
8.  Peer Reviews is the practice of sending the medical reports and diagnostic reports to another medical provider for a review of the medical information for the purpose of confirming the appropriateness and quality of the medical care being provided. Using physician review is in my opinion one of the most useful tools an employer can use. They can read he medical reports to find what’s NOT there. They look for other possible causes of injury, appropriateness of care and make sure employees go to the correct specialists.  This service may be called Peer-to-Peer.
 
 
9.  The era of computers has created the ability to use technology to obtain information that would not otherwise be available including:
 
1.      Predictive Modeling is used to identify early on those claims that have a high probability of becoming expensive claims so they can be acted upon quickly.
 
2.      Data Mining is used to identify high cost medical providers; medical providers who are slow to return the employee to work and to identify other claim related information that impacts claim cost.
 
3.      Benchmarking is using the known information about your workers’ compensation claims to compare your cost control results against others employers or insurers. (WCxKit)
 
10. Send me your ideas for YOUR favorite Medical Cost Containment Strategy. Let me know if it’s OK to share your ideas. Please write up to 200 words.

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.

 
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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.
Filed Under: Medical Cost Containment, Medical Issues, WC 101 Tagged With: , , , , , ,

Medcor Receives 2011 Innovation Award

February 2, 2011 by Leave a Comment
One of my favorite services has won the 2011 Innovation Award by Business Insurance. And, for good reason.  
 

Business Insurance (a division of Crain Communication) named Medcor one of its 2011 Innovation Award winners. This prestigious annual award recognizes “leadership, inventiveness and ingenuity in products and services designed for professional risk managers.” An independent panel of judges, made up of active risk management professionals, which were announced on Business Insurance website.
 
 
Medcor establishes onsite medical and wellness clinics, provides nurse triage and pre-employment post offer employment screening. The impact of having significant up front services can reduce the number of lost time claims significantly, often converting them to self-care and clinic care rather than emergency care. And on-site clinics can be a huge advantage for employers that want to improve overall wellness of employees.
 
 
Workers Comp Kit Blog congratulates Medcor, Inc. on receiving this prestigious award and is proud they advertise with us.  Having visited with MedCor several months ago, we learned first hand what an impressive operation it is and beleive it's one of the best proactive services companies can use to make sure employees get the best care immediately after an injury.
 
 
Medcor was nominated by several of their clients for their innovative services. We are guessing the award relates to their triage servcies because they earned three U.S. patents in 2010. Medcor is joined by a select group of other innovative companies. 
 
 
Mr. Smith said, “Everyone at Medcor greatly appreciates the support of all our clients and partners who have helped to make our innovative services a success!”
 
 
He can be contacted at: Office: (815) 363-9500, ext. 5558, Direct Line: (815) 759-5458, Fax: (815) 363-3634, 4805 West Prime Parkway/PO Box 550, McHenry, IL 60050. And by email: csmith@medcor.com. Visit MedCor at: https://www.medcor.com/home/home.asp
 
 

Learn more about the award by following the links at Business Insurance website at www.BusinessInsurance.com or at www.BusinessInsurance.com/Innovation2011.

 
WORK COMP CALCULATOR:   http://www.LowerWC.com/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.
Filed Under: Medical Issues, Wellness Programs and Workers Compensation Tagged With: , ,

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