Upset About your Workers' Compensation costs? What are you going to do about it?

There's ample research and discussion about factors that may lead to delayed recovery or poorer outcomes for workers' compensation claims.  We're all really good at pointing the finger and saying that it's because of the doctor, the unmotivated injured worker, or the employer who just doesn't get it.  I'd like to ask one simple question to those who are frustrated or angry about workers' compensation outcomes.  What are you going to do about it?

In the extreme case, an employer could shut down the business, throw in the towel.  Highly unlikely.  Realistically there are several steps employers and other stakeholders can take to GET INVOLVED in their claim management programs.  Here's just a few of my favorite.

• Report all injuries as soon as possible.  It's fairly common knowledge that the sooner everyone knows about an injury, the sooner it can be managed.  This leads to the next important point.
• Get the injured worker prompt appropriate medical care.  Get them the best care a workers' compensation dollar can buy.  If you want the best outcome, why would you skimp here?  Who would you want to see if it were your injury -- the doctor who just processes injuries and prescribes anti-inflammatories, tells you to follow up with your family physician if not better in a week or the occupational health physician who understands how to approach work injuries, what is necessary to help you get better and back to work, and what the signs of trouble may be?  Do you want a physician who follows what massive amounts of research says provides the best outcome, or the doctor who disregards evidence-based medicine in exchange for their anecdotal, 30 year old medical school training.  I wouldn't want a mechanic who only worked on cars from the 1970s to work on my 21st century car that's basically a computer running on gasoline (or electric, for that matter).  Get your employees to the best providers who are on top of the most current medical practices, and follow evidence-based treatment guidelines.
• Reduce delays in care by getting treatment approved, appointments scheduled, and referrals made TIMELY.  The sooner we can help that injured worker get the care they need, the sooner everyone can learn what the true injury is, what the treatment plan will look like and assess the RTW opportunities.  Nurse case managers can help with this process.
• Communicate effectively!  Communication is often the cause and the solution to all problems in a claim.  Keep everyone in the loop -- find a way to do it. Maybe it's a list of everyone who you need to update, written down on a sheet of paper.  Maybe it's an email distribution list that you create for each employee's claim.  Whatever your strategy is, keep everyone up to date.  As the saying goes, communicate by a factor of 10, and then say it one more time.  This group includes the injured worker, the employee's supervisor, the claim representative, nurse case manager, medical providers, and whoever else may be involved in the claim.  Documentation will be key in communicating technical, detailed information.  One example of this is the injured worker's pre-injury job description.  Document it, send it around for review and approval (including the injured worker) and then send it to the treating physician, physical therapist, and nurse case manager.  After all, how can you plan to get an injured worker back to work if you don't know what they need to do?  Identify barriers to return to work early on and develop a plan to address them.

These suggestions are based upon evidence.  Researchers from the Department of Physiotherapy and the Department of Epidemiology and Preventative Medicine at Monash University in Melbourne, Australia conducted a study involving the aforementioned interventions.  The results?  In their study, their intervention reduced costs associated with RTW claims by 34% and cut the days away from work by 58% (Iles & Wyatt, 2013).

References:
Iles, R. A., & Wyatt, M. (2013). Applying the evidence: a real-world example of an intervention to reduce workers' compensation costs. Physical Therapy Reviews, 18(5), 395-402.

Nurse Case Managers are NOT the Claims Police

This week's post comes to us from Eastern's own Director of Medical Cost Management, Nancy Crago, RN, BS, CCIM, AIC.  Nancy has over 35 years of nursing experience as well as 16 years of insurance experience.  She has had the opportunity to work directly in many areas of workers' compensation claims ranging from telephonic case management, claims adjusting, and supervision of adjusters and case management teams.  

What is a case manager?

The Case Management Society of America defines a case manager as a health care professional who is responsible for utilizing the case management process for individuals with health-related needs, with the goal of maximizing their wellness, autonomy and appropriate use of resources.  

What experience do case managers have?
Nurse Case Managers are registered nurses with at least 10 years of nursing experience.  Many nurses have advanced degrees and have specialized clinical skills and knowledge.  In addition, many nurses have national certification from organizations which focus on case management.  These include CCM, CRRN, and CDMS.  Continuing education is required to maintain professional licenses and national certifications.

Nurse Case Managers who work in the workers’ compensation environment generally have backgrounds in orthopedics, neurology, critical care, emergency trauma, general surgery, rehabilitation, or occupational health.  

Exactly what is it that nurse case managers do?
Case Managers have several roles – they are advocates, facilitators, coordinators and educators.  The foremost role is advocate.  Whenever a case manager works with an injured worker, the nurse establishes a relationship with that person.  The case manager and injured worker establish goals and plans to meet those goals.  While working as a case manager in workers’ comp it is essential that the case manager inform the injured workers that any information related to the claim and its outcome will be shared with the physician(s), claims representative, and employer.

How can employers maximize the benefits of case managers?
Collaboration is the key to a successful outcome with a case manager.  Case managers are looking for a win-win situation – the injured workers returns to wellness and the employer regains a productive employee.  Although the case manager will be an expert about the injury and treatment, he or she may not be an expert about the injured worker’s job and specific requirements.  Share a detailed job description with the case manager.  This will foster understanding about your business.  This knowledge and a written job description helps the case manager to clearly discuss how the injured worker can safely return to work during recovery from the work injury.   Use the case manager’s medical knowledge to help design a job around any restrictions the physician may order.  Ask questions about the treatment plan – how long will treatment last, are there other effective treatments. 

Case managers are NOT the "claims police"
Injured workers (and some mistaken employers) may think that the case manager is assigned as a policeman.  Nothing can be further from the truth.  Medical care is becoming more and more complex.  The case manager will assist the injured worker to understand the treatment plan, medications, and why early return to work is essential for a full recovery. 

Because the case manager brings medical expertise to the claim, he or she will always be pushing toward the next outcome and goal.  Expect the case manager to provide suggestions and recommendations for next steps.

Through education and experience, a case manager brings medical expertise to the claim.  A case manager also helps to coordinate care with a variety of healthcare providers—physicians, therapists, pharmacists, etc.   Case Managers are not “claims police”.  Their only focus is on returning injured workers to wellness through appropriate medical care.  As nurses, case managers are advocates for the injured worker, which benefits the injured worker and the employer. 

Thank you to Nancy for sharing her experience and insight on some of the many aspects of case management!