Achieving More Fluid Case Management
Risk management practitioners point to a number of factors that influence the outcome of workers’ compensation claims. But readily identifiable factors shouldn’t necessarily be managed in a box.
To identify and discuss the changing issues influencing workers’ compensation claim outcomes, Risk & Insurance®, in partnership with Duluth, Ga.-based Healthcare Solutions, convened an April roundtable discussion in Philadelphia.
The discussion, moderated by Dan Reynolds, editor-in-chief of Risk & Insurance®, featured participation from four tenured claims management professionals.
This roundtable was ruled by a pragmatic tone, characterized by declarations on solutions that are finding traction on many current workers’ compensation challenges.
The advantages of face-to-face case management visits with injured workers got some of the strongest support at the roundtable.
“What you can assess from somebody’s home environment, their motivation, their attitude, their desire to get well or not get well is easy to do when you are looking at somebody and sitting in their home,” participant Barb Ritz said, a workers’ compensation manager in the office of risk services at the Temple University Health System in Philadelphia.
Telephonic case management gradually replaced face-to-face visits in many organizations, but participants said the pendulum has swung back and face-to-face visits are again more widely valued.
In person visits are beneficial not only in assessing the claimant’s condition and attitude, but also in providing an objective ear to annotate the dialogue between doctors and patients.
“Oftentimes, injured workers who go to physician appointments only retain about 20 percent of what the doctor is telling them,” said Jean Chambers, a Lakeland, Fla.-based vice president of clinical services for Bunch CareSolutions. “When you have a nurse accompanying the claimant, the nurse can help educate the injured worker following the appointment and also provide an objective update to the employer on the injured worker’s condition related to the claim.”
“The relationship that the nurse develops with the claimant is very important,” added Christine Curtis, a manager of medical services in the workers’ compensation division of New Cumberland, Pa.-based School Claims Services.
“It’s also great for fraud detection. During a visit the nurse can see symptoms that don’t necessarily match actions, and oftentimes claimants will tell nurses things they shouldn’t if they want their claim to be accepted,” Curtis said.
For these reasons and others, Curtis said that she uses onsite nursing.
Roundtable participant Susan LaBar, a Yardley, Pa.-based risk manager for transportation company Coach USA, said when she first started her job there, she insisted that nurses be placed on all lost-time cases. But that didn’t happen until she convinced management that it would work.
“We did it and the indemnity dollars went down and it more than paid for the nurses,” she said. “That became our model. You have to prove that it works and that takes time, but it does come out at the end of the day,” she said.
The ultimate outcome
Reducing costs is reason enough for implementing nurse case management, but many say safe return-to-work is the ultimate measure of a good outcome. An aging, heavier worker population plagued by diabetes, hypertension, and orthopedic problems and, in many cases, painkiller abuse is changing the very definition of safe return-to-work.
Roundtable members were unanimous in their belief that offering even the most undemanding forms of modified duty is preferable to having workers at home for extended periods of time.
“Return-to-work is the only way to control the workers’ comp cost. It’s the only way,” said Coach USA’s Susan LaBar.
Unhealthy households, family cultures in which workers’ compensation fraud can be a way of life and physical and mental atrophy are just some of the pitfalls that modified duty and return-to-work in general can help stave off.
“I take employees back in any capacity. So long as they can stand or sit or do something,” Ritz said. “The longer you’re sitting at home, the longer you’re disconnected. The next thing you know you’re isolated and angry with your employer.”
“Return-to-work is the only way to control the workers’ comp cost. It’s the only way,” said Coach USA’s Susan LaBar.
Whose story is it?
Managing return-to-work and nurse supervision of workers’ compensation cases also play important roles in controlling communication around the case. Return-to-work and modified duty can more quickly break that negative communication chain, roundtable participants said.
There was some disagreement among participants in the area of fraud. Some felt that workers’ compensation fraud is not as prevalent as commonly believed.
On the other hand, Coach USA’s Susan LaBar said that many cases start out with a legitimate injury but become fraudulent through extension.
“I’m talking about a process where claimants drag out the claim, treatment continues and they never come back to work,” she said.
Social media, as in all aspects of insurance fraud, is also playing an important role. Roundtable participants said Facebook is the first place they visit when they get a claim. Unbridled posts of personal information have become a rich library for case managers looking for indications of fraud.
“What you can assess from somebody’s home environment, their motivation, their attitude, their desire to get well or not get well is easy to do when you are looking at somebody and sitting in their home,” said participant Barb Ritz.
As daunting as co-morbidities have become, roundtable participants said that data has become a useful tool. Information about tobacco use, weight, diabetes and other complicating factors is now being used by physicians and managed care vendors to educate patients and better manage treatment.
“Education is important after an injury occurs,” said Rich Leonardo, chief sales officer for Healthcare Solutions, who also sat in on the roundtable. “The nurse is not always delivering news the patient wants to hear, so providing education on how the process is going to work is helpful.”
“We’re trying to get people to ‘Know your number’, such as to know what your blood pressure and glucose levels are,” said SCS’s Christine Curtis. “If you have somebody who’s diabetic, hypertensive and overweight, that nurse can talk directly to the injured worker and say, ‘Look, I know this is a sensitive issue, but we want you to get better and we’ll work with you because improving your overall health is important to helping you recover.”
The costs of co-morbidities are pushing case managers to be more frank in patient dialogue. Information about smoking cessation programs and weight loss approaches is now more freely offered.
Managing constant change
Anyone responsible for workers’ compensation knows that medical costs have been rising for years. But medical cost is not the only factor in the case management equation that is in motion.
The pendulum swing between technology and the human touch in treating injured workers is ever in flux. Even within a single program, the decision on when it is best to apply nurse case management varies.
“It used to be that every claim went to a nurse and now the industry is more selective,” said Bunch CareSolutions’ Jean Chambers. “However, you have to be careful because sometimes it’s the ones that seem to be a simple injury that can end up being a million dollar claim.”
“Predictive analytics can be used to help organizations flag claims for case management, but the human element will never be replaced,” Leonardo concluded.
This article was produced by Healthcare Solutions and not the Risk & Insurance® editorial team.
Bundling Medical Services Offers Clear-Cut Advantages to Payers
After all, concerns about putting “all your eggs in one basket” exist for a reason. However, when it comes to medical management services, before deciding one way or the other, payers should take a close, hard look at the advantages of choosing a single source for required medical services.
In fact, many payers have been surprised by the advantages of choosing a bundled services approach, said Joe Boures, president and chief operating officer at Healthcare Solutions, the Duluth, Ga.-based health services provider of integrated solutions to the property and casualty markets, specializing in workers’ compensation and auto liability/PIP.
“The ‘eggs in one basket’ concern has been offset by the benefits of streamlined technology and implementation processes, improved patient care and the reduced administrative work inherent in managing multiple vendors,” Boures said. “Apart from those fundamental advantages, payers who have chosen to bundle services have also benefitted from improved buy rates, as well as the capability to improve patient outcomes with increased visibility into a claim.”
Open to a New Philosophy
Boures explained that by shifting to a bundled services philosophy many of the company’s customers have been able to categorically and consistently apply guidelines and best practices across all services. As a result, these payers approach medical management holistically, with services administered consistently, regardless of the type of service.
“Adopting this service delivery philosophy means you can consistently apply supply chain management techniques when managing medical providers — whether it’s a PPO provider or a specialty provider such as a physical therapist or durable medical equipment supplier,” Boures said. “It’s about creating a process infrastructure focused on the injured worker, rather than disparately managing isolated services. It reduces anything falling through the cracks, which can result from a less cohesive, coordinated process.”
In fact, when opting for an unbundled strategy, one obvious outcome is losing control over how programs are managed, with likely inefficiencies soon to follow (that is, if you can even spot them).
Underlying Technology/Implementation Process
Efficient medical management begins with a single eligibility file, said David George, chief executive officer at Healthcare Solutions. According to George, it is essential to choose a partner with the right technology infrastructure, enabling a single eligibility file and file exchange process to be deployed across all programs. Rather than “building bridges” with multiple vendors, he said, a one-time implementation can streamline processes and result in consistency in data exchanges, saving valuable time and effort.
“Tight customer integration creates systems that talk to each other on the front-end, while the back-end system is used to manage suppliers on the customer’s behalf,” George says. “With fewer partners, payers can invest more time truly integrating systems that really communicate, further improving administrative efficiencies.”
“It’s about creating a process infrastructure focused on the injured worker, rather than disparately managing isolated services.”
— Joe Boures, President and Chief Operating Officer, Healthcare Solutions
Reduced Administrative Burden and Improved Patient Care
Of course, while the right technology is essential, there’s also the human element in managing every claim. Coordination of medical services by a single partner provides an additional layer of clinical oversight that is not possible when services are independently coordinated by multiple partners. In addition, when partners are consolidated into a single source, adjusters don’t have to think about whom are “they going to call.” The result is improved network penetration and less leakage that often occurs when referrals are sent to un-contracted providers. Also, this reduces inconsistent protocols applied to the claim, such as generic substitution in durable medical equipment, for example, or use of utilization review triggers.
“Service bundling has afforded many of our customers an integrated view of how medical dollars are being spent, and uncovered opportunities to further improve medical management, ultimately affecting patient care, loss ratios and reserves,” George said.
As a critical part of reducing administrative burdens, integrated reporting supplied by a single partner enables payers to give brokers and payer clients a more granular look into how dollars are being managed. More sophisticated, consistent reporting has helped payers demonstrate exactly how they are being good stewards of employers’ money. Other advantages include:
- Aggregated reporting — Ensures consistent application across products.
- A single contract — Used with service level agreements to hold partner accountable for quality and service delivery.
- Consolidated partnership meetings — Results in a “clearer, bigger picture,” which in turn helps the partner provide better insights/recommendations.
George said a good example of how a single source provider can be an advantage is when it uses pharmacy reporting to identify claimants that may trigger in-home analyses or home health services. Why? Because pharmacy typically is an early indicator of what’s to come with a claim.
“With fewer partners, payers can invest more time truly integrating systems that really communicate, further improving administrative efficiencies.”
— David A. George, Chief Executive Officer, Healthcare Solutions
“The idea is to use the data on a preventive basis to mitigate further complexities in the claim,” George said. “In so many cases, identifying an early trend, such as opioid or anti-depressant use, has resulted in developing successful treatment strategies that incorporate case management or home health services, which can reduce further losses, aid in return-to-work, etc.”
Bundled vs. Unbundled: The Decision
George concluded that even with all the obvious advantages of choosing a bundled solution, there will never be a “one size fits all” approach to a medical services management strategy. Each company must decide what model is best for their situation. As an interim step, George recommended a path that can give payers the chance to move into a single source provider gradually.
“Even if all services are not bundled, it often makes sense to combine two or more together to get a sense of how it will work for your organization,” George said. “It’s a great way to test the water.”
For more information about bundling medical services, contact Rich Leonardo, chief sales officer, at 678-347-2393 or firstname.lastname@example.org.