2015 NWCDC

Best Use of Nurse Case Managers

Nurses with soft skills can significantly improve outcomes on complex claims.
By: | November 13, 2015 • 2 min read
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Nurse case managers can vastly improve outcomes for injured workers and save a bundle for payers. The trick is to understand which claims will benefit from intervention and to use nurses with the right skill set.

“If an injury occurs from lifting equipment or falling from a height, the claim needs a nurse,” said Stephanie Perilli, senior director of medical and health management for The Home Depot, during a session at the National Workers’ Compensation and Disability Conference® & Expo on November 12.

In a comparison of claims more than 24 months old, the company saw a 12 percent savings on paid medical dollars and a 28 percent reduction on paid loss dollars for claims with nurse involvement.

For non-catastrophic cases, the company uses a model to determine whether to involve a nurse.

“Our results have significantly improved over the last three years,” she said.

In a comparison of claims more than 24 months old, the company saw a 12 percent savings on paid medical dollars and a 28 percent reduction on paid loss dollars for claims with nurse involvement.

But not every claim is appropriate for nurse intervention. A recent study determined that 25 variables, especially when some are in combination, can serve as triggers.

“If you’ve got an injured worker who is over 35, has no college degree, has injured a certain body part and undergone certain medical treatment, get a nurse as soon as possible,” said Mary O’Donoghue, VP of medical services for Helmsman Management Services.

In addition to the complexity of a claim, the nurse’s skill set can determine the value of involvement. Those nurses who are trustworthy can make the most difference.

“They can identify problems, educate folks, and redirect where needed,” O’Donoghue said.

Helmsman has found the most effective soft skills needed to move claims forward are communication with all parties involved, including family members; empathy, to establish trust with the injured worker; and collaboration, to make sure there is a plan in place and everyone involved is on the same page.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at riskletters@lrp.com.
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2015 NWCDC

Comp’s Most Bizarre Cases

One expert in workers’ comp law recounts some of the most interesting cases of the year.
By: | November 13, 2015 • 2 min read
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Though workers’ compensation law “can be dry at times,” there is no shortage of interesting cases that come across the desk of Thomas Robinson, J.D., co-author of Larson’s Workers’ Compensation Law.

“We’re talking about some really funny circumstances,” he said during a presentation at the National Workers’ Compensation and Disability Conference® & Expo in Las Vegas on November 12.

In one case from this year, a nursing home decided to conduct an active shooter drill, without advising residents and employees. It hired a local sheriff to play the shooter.

In one case from this year, a nursing home decided to conduct an active shooter drill, without advising residents and employees. It hired a local sheriff to play the shooter.

“This particular sheriff thought he was meant for the stage,” Robinson said.

The sheriff burst into the building, gun drawn, and threatened to kill an employee unless she did exactly what he said. The employee filed a civil suit against the employer for the emotional trauma caused by the drill.

“There are certain risks you have to think about it when you go to work,” Robinson said.

“The court determined that, as a nursing home employee, having a gun held to your head is not one of them.”

In another case, a Spanish-speaking employee of Butterball Corp. strained his shoulder while picking up a frozen 80-pound turkey.

He was sent to a major medical center where he was catheterized, because the doctors mistook his gesturing to his shoulder to mean chest pain, and feared a heart attack.

The misunderstanding resulted in hours of unnecessary testing and a $20,000 medical bill, for which the employer was held responsible.

Ultimately, determination of compensability in Robinson’s bizarre cases depends on specific state laws.

Some require a strong causal relationship between the workplace or nature of work and the injury. Others give more leeway to the worker.

In any event, as Robinson attests, workers’ compensation is actually anything but dull or dry.

Katie Siegel is a staff writer at Risk & Insurance®. She can be reached at ksiegel@lrp.com.
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Sponsored: Liberty Mutual Insurance

The Doctor as Partner

Consulting clinical expertise can vastly improve disability and absence management outcomes.
By: | January 4, 2016 • 6 min read

Professionals helping employees return to work after being on disability or a leave of absence face many challenges. After all, there is a personal story behind each case and each case is unique.

In the end, the best outcome is an employee who returns to the job healthy and feeling well taken care of, while at the same time managing the associated claim costs.

Learn what most employers want from their group disability and life benefits program.

While many carriers and claims managers work toward these goals, in the end they often tend to focus on minimizing costs by aggressively managing claims to get the worker back on the job, or they “fast track” claims, approving everything and paying little attention to case management.

Aggressively managed claims can leave many employees and their doctors feeling defensive and ill-at-ease, creating an adversarial relationship that ultimately hinders return to work and results in higher direct and indirect employee benefit costs for the employer. Fast track or non-managed claims can lead to increased durations, costs and workforce productivity issues for employers.

Is it possible to provide a positive employee benefit experience while at the same time effectively managing disability and lowering an employer’s overall benefit costs?

A Unique Approach

Yes.

Liberty Mutual Insurance’s approach to managing disability and absence management focuses on building consensus among all stakeholders – the disabled employee, treating physician, employer and insurer. And a key component of this process is a large team of consulting physician specialists, leading practitioners from a variety of specialties, highly regarded experts affiliated with leading medical universities across the country.

“About 16 years ago, our national medical director, Dr. Ed Crouch, proposed that if we worked with a core group of external consulting medical specialists – rather than sending most claims for Independent Medical Evaluations – we could do a better job making disabled employees and their attending physicians comfortable, and therefore true partners in producing better disability management outcomes and employee benefit experiences,” said Tim Kastrinelis, senior vice president, Distribution Partnerships at Liberty Mutual Benefits.

“In this way, our consulting physician and the attending physician are able to work with the disability case manager, the employee and the employer to deliver a coordinated, collaborative approach that facilitates a productive lifestyle and return to work.”

The result of Dr. Crouch’s initiative has produced positive results for the clients of Liberty Mutual Insurance. This consensus building approach to managing disability with consulting physician expertise has helped achieve industry leading client retention results over the past decade. In fact, 96 percent of Liberty Mutual’s group disability and group life clients renew their programs.

LM_SponsoredContent“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders. …In the end, it’s a win-win for all.”
–Tim Kastrinelis, Senior Vice President, Distribution Partnerships, Liberty Mutual Benefits

A Collaborative Approach

In the case of complex disability medical health situations, Liberty Mutual’s disability case managers play a vital role in seeking additional expertise—an area where the industry’s standard has been to outsource the claimant for independent medical examinations.

However, Liberty Mutual empowers its disability case managers with the ultimate responsibility for the outcome of each claim. The claimant and the case manager stay together throughout the life of the claim. This relationship is the foundation for a collaborative approach that delivers a better employee benefit experience and enables the claimant to return to work sooner; which more effectively controls total disability claim and absence costs.

Sending a disabled employee with complex medical needs to an external specialist may sound like a cost-effective path, but it often comes at the cost of sacrificing the relationship and trust built between the employee and case manager. The disabled employee must explain their medical history to a new clinician, which he or she is often reluctant to do. The attending physician may be uncooperative as this move can appear to question his or her treatment plan for the employee.

As a result, the entire claims process takes on an adversarial atmosphere, building major roadblocks to the ultimate goal of helping the claimant return to a productive lifestyle.

Liberty Mutual takes a different approach. Nearly 100 physicians representing more than 30 medical specialties are available to consult with its medical and claims professionals, working side-by-side with case managers.

More than 95 percent of these consulting physicians are in active practice, and therefore up-to-date on the latest clinical best practices, treatment guidelines, therapies, medications, and programs. Most of these physicians are affiliated with leading medical universities across the country. “We recruit specialists from around the country, getting the best from such prestigious institutions as Harvard, Yale, and Duke,” said Kastrinelis.

These highly-credentialed physicians help case managers focus on providing the support needed for the disabled employee to successfully return to work as quickly as appropriate. Their collaborative work with the attending physicians provides the behind-the-scenes foundation that leads to a positive claimant experience, results in a better outcome for the claimant, and more effectively reduces total claim costs.

Coordinated Care Plan

When one of these consulting physicians reaches out to an attending physician, there’s an immediate degree of respect and high regard for his or her opinion. This helps pave the way to working together in the best interest of the employee, improving treatment plans and return to work results.

In this process, the claimant is not sent to yet another doctor; instead, the consulting specialist works with the attending physician to help fill in the gaps of knowledge or provide information that only a specialist would have. Although not an opportunity to direct care, these peer-to-peer discussions can help optimize care with the goal of helping the employee return to work.

The attending physician may have no knowledge of the challenges the employee faces in order to return to work. A return to work plan created in concert with the specialist, disability case manager, employer, and attending physician can set expectations and provide the framework for a proactive and effective return to a productive lifestyle.

“Our consulting physicians bring sophisticated medical expertise to the discussion, and help build consensus around a return-to-work plan, helping us more effectively impact a claim’s outcome and costs, and at the same time provide a better claimant experience,” said Kastrinelis.

“We can work more collaboratively with the attending physician, manage expectations, and shepherd the employee through the process much more effectively and in a much more high-touch, caring, and compassionate manner. Overall, we’re able to produce better outcomes as a result of this consensus building approach.”

Better Outcomes

“Our approach – including the use of consulting medical experts – helped us significantly reduce disability costs over two years for one large health service company,” notes Kastrinelis. “We cut average short-term disability claim durations by 4.2 days in that time, while increasing employee satisfaction with our unique disability management model and collaborative, partnership approach.

How did Liberty Mutual’s unique approach lower claim costs, reduce disability duration and improve the benefit experience for one customer?

“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders,” said Kastrinelis.

“Plus, we, the employee, and the employer also get the bonus of creating a better employee benefit experience. This model has shaped our disability and absence management program to more aptly reflect our core mission of helping people live safer, more secure lives. In the end, it’s a win-win for all.”

How does Liberty Mutual provide a superior employee benefit experience?

Tim Kastrinelis can be reached at timothy.kastrinelis@libertymutual.com. More information on Liberty Mutual’s group disability and absence management offerings can be seen at https://www.libertymutualgroup.com/business-insurance/business-insurance-coverages/employee-benefits.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.




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Liberty Mutual Insurance offers a wide range of insurance products and services, including general liability, property, commercial automobile, excess casualty, workers compensation and group benefits.
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