Telephonic Case Management

As Workers’ Compensation costs continue to escalate, decision-makers with bottom line accountability are seeking more powerful methods of controlling claims costs. Employers know all too well the costly effects of work injuries, from the escalating medical costs to lost productivity.

Employers and Insurance Companies alike are realizing that work place injuries must be managed and controlled from the point of injury until return to work is achieved and the injury is resolved. Early involvement of a registered nurse in the initial assessment and management of the injury helps to facilitate a medically appropriate discharge from care by the physician and accelerates a return to work thereby achieving rapid case closure.

In the past, when an injury occurred the adjuster was responsible for adjusting the claim and controlling the medicals on the file. One might say that the adjuster was considered the “train engineer” of the claim. If the injury was considered a catastrophic, immediate referral was made to an outside nurse case manager to coordinate the medical aspects of the file. If the injury was not serious, a referral was usually not made to the nurse until after three months or sometimes longer. In this instance, the nurse would be considered the “caboose” of the claim.

With the advent of Telephonic Case Management, the nurse is now a “co-engineer” with the adjuster, giving the adjuster invaluable medical and disability information at the inception of the claim, thereby enabling the adjuster to make informed claim decisions.

Early intervention, also known as “telephonic nurse case management”, is a concept that revolves around early identification of the work related injury/illness and early involvement by a Registered Nurse for the initial assessment and management of the injury. The telephonic case manager understands that Workers’ Compensation costs are controlled through input into the decisions made between physicians and injured workers. Active involvement of a nurse in both the medical aspect as well as the vocational implications is occurring in the beginning when costs and the attitude of both the employer and employee toward return to work can have the most impact.

Usually, Workers’ Compensation Medical Only and Lost Time cases are phoned, faxed or electronically submitted to the telephonic “nurse case manager.” The nurse secures medical information from the injured worker to include history, symptoms, complaints and other healthcare problems. The nurse will also obtain information regarding the most recent medical care provider and health insurance information. The nurse makes the necessary contacts, by phone, with all parties to identify the medical issues. The nurse will maintain contact with the Injured Worker, Employer, Treating Medical Provider and the Claim Representative to communicate the medical progress of the injured employee. The nurse will also work directly with the employer to facilitate early return-to-work and may continue to provide telephonic monitoring of the return to work status on an “as needed basis”.

The overall goal of this program is to facilitate “a medically appropriate” discharge from care by the treating provider and accelerate a return to work.

By utilizing standards of care, the nurse will evaluate the medical diagnosis, treatment plan, prognosis, anticipated return-to-work date and potential temporary or permanent disability. The nurse makes recommendations, communicates this information to the adjuster and provides the adjuster with the medical information needed to make informed claims decisions.

Early Intervention/Telephonic Case Management Procedures

Initial contact is made within 24 hours of receipt of First Report of Injury or referral.

Initially, the employer will be called to verify the injury.

The injured worker will be contacted to explain the telephonic case manager’s role and to obtain a description of the injury, past medical history and pre-injury job. It will be determined if the employee has already sought treatment.

If needed, the provider will be contacted to set up an appointment. The physician will also be provided with a past medical history. A medical report will be obtained which will include diagnosis, treatment recommendations, work status and industrial causation of the injury.

The nurse will forward this information to the employer and the insurance adjuster within 24 hours of receipt.

The nurse will maintain contact with the injured worker by telephone to:

Assess the injured Worker’s symptoms, level of understanding of their medical condition and prescribed medical treatment

Assess the injured Worker’s compliance with treatment recommendations.

The nurse will contact the employer to discuss:

Physical demands of pre-injury job

Current physical capabilities

Development of a modified position

Coordination of return to work

At all times, the nurse will maintain communication between the employer, the medical provider and the insurance adjuster.

If disability exceeds seven days, the adjuster will be notified so that indemnity benefits can be calculated.

The nurse will make recommendations to the claims adjuster. Upon approval, the nurse will complete the following:

Scheduling of appointments (MRI, EMG, FCE, etc.)

Independent Medical Evaluations

For catastrophic injuries, complex medical conditions or for a lost time claim post 90 days without an immediate projected return to work date, it is recommended that on-site case management be considered. On-site case management is provided by highly trained and experienced registered nurses who are skilled at handling severe injuries and complex medical conditions. Their experience and knowledge of the local medical providers, facilities and community resources enables them to control costs and to quickly move cases towards a successful resolution. The decision to employ on-site medical case management rests with the employer and/or the adjuster.

If the claim is denied, case management services are discontinued after the treating provider is notified of denial, so as to assure additional medical services will not be provided.

Key Components of Telephonic Nurse Case Management:

Telephonic Nurse Case Managers should have at least five (5) years of clinical experience in a hospital setting, in addition a minimum of one (1) year of Workers’ Compensation case management experience is preferred.

Telephonic Nurse Case Managers must be pro-active.

Telephonic Nurse Case Managers must follow up with the physician within 24 hours of the appointment, if report has not been received.

Telephonic Nurse Case Managers coordinate and facilitate diagnostic tests, prescriptions, therapies, transportation, etc.

Telephonic Nurse Case Managers need good communication skills. Telephonic Nurse Case Managers need to communicate not only with the employer and the adjuster, but with the injured worker and the physician.

Regardless of whether you choose traditional insurance or opt to self insure your workers’ compensation exposure, you can elect to “carve out” the Telephonic Nurse Case Management/Early Intervention component to an independent case management company to take advantage of the flexible, innovative, and cost-effective managed care solutions available outside of your internal workers’ compensation program.

In summary, Telephonic Nurse Case Management, if used properly, improves the quality and levels of teamwork, cooperation, and communication between the employer, employee, treating physicians, and insurer, and can save your company a significant amount of money in both medical and indemnity costs.