Early Case Management Speeds RTW, Report Says
Workers’ comp payers need to develop their own tipping points when seemingly routine claims escalate to high-cost levels. That’s among the strategies suggested in a new white paper.
Genex, a managed care firm, analyzed 46,000 claims over 12 months to identify characteristics that may signal a rapid escalation into excessive costs. While admitting there is no magic formula, the company says there are indications that a claim may be one of the estimated 5 percent that will turn into long-term, chronic cases that may cost millions of dollars. Among them are:
- Poor initial physician diagnosis
- Doctor hopping (e.g., three or more specialty physicians)
- Lack of modified work duty options
- Poor employee/employer relationships
- Psycho-social factors, including poor family support
- Preexisting conditions
- Alcohol or drug dependence
“One of the most important steps employers and carriers can take is to analyze claims and to engage telephonic case management for even routine injuries when two or more red flags are identified,” said Pat Chavanu, senior vice president at Genex. “As an industry we have to move away from setting arbitrary dollar figures for when to bring in case management; we need to utilize it earlier when it can make a difference in terms of costs, outcomes and the well-being of the worker.”
According to the analysis, delaying case management for a year can decrease the likelihood of the injured worker returning to work by nearly 20 percent. Claims that use case management in the first nine months are two times more likely to have a successful RTW as those referred three years after the incident.
“This does not mean, however, using case management for all claims,” the paper said. “Benchmarks, data, organizational culture and goals must be defined and incorporated into employer tipping point criteria.”
The company advises payers to hold case management programs accountable. “Look at their costs, how quickly they return employees to work, and whether they help to reduce litigation,” the paper said. “Does the organization also tell you when case management is not necessary? Ask claimants about their experience. Is it positive, negative?”
Payers should develop criteria based on the organization’s RTW goals, the paper advised. Also, they should make sure injured workers have access to a network of savvy workers’ comp providers, and give adjusters tools and resources to identify red flag claim characteristics.
The Balancing Act of Rehabbing Injured Workers
Putting injured employees at ease, educating cost-conscious employers, and tactfully questioning doctors’ treatment decisions are among the responsibilities workers’ compensation nurse case managers must balance. Added to that, their role has grown increasingly demanding.
More regulatory requirements and claims-payer demands, rising claim complexity, and more service providers involved in a claim’s management make it a very different job today than it was a few years ago, experts said.
Despite the job’s heightened challenges, however, some things remain the same, said Anne Kirby, chief compliance officer and vice president of medical review services for Rising Medical Solutions.
“I find in hiring nurses that the one thing that hasn’t changed is their interest and their dedication to doing the right thing for injured workers,” said Kirby, a registered nurse.
“I don’t see that that has changed at all.”
While guiding injured workers through workers’ comp medical treatment is a primary job focus, the nurses also represent the interests of employers and other claims payers.
“You either love this [work], or you hate it.” — Kim Weaver, an RN and director of professional services at M Hayes
They often form the front line of claims management to ensure workers receive the proper care necessary to expeditiously return to the job, while making sure payers don’t fund unnecessary claim expenses.
That often requires advocating for workers while collaborating with doctors, attorneys, therapists and other service providers. Other times it requires questioning the necessity of those service providers or their decisions.
“In the world of comp you have people who are welcoming you,” including doctors and patients, said Kim Weaver, an RN and director of professional services at M Hayes, a case management company recently acquired by GENEX Services LLC.
“They want to work with you because they see you as an advocate or as a conduit [for their medical care].”
But there are also physicians who believe insurance industry nurses are only there to delay or stop their treatment plans, Weaver said.
Requesting that a doctor consider a different treatment path requires tact and careful wording to avoid offending egos, said Susan Mitchell, an RN and case manager at The Travelers Cos. Inc.
“It’s all a matter of how you present it to them,” she said. “If you come across saying, ‘Your decision on this treatment is not working,’ then they will get defensive and not want to talk to you.”
She carefully explains to doctors when she observes that a patient isn’t improving and asks the physician if they can “talk about something else that might help” the patient, Mitchell said.
Gaining Worker Trust
A key challenge is winning worker trust, particularly for telephonic case managers who don’t have the advantage of working bedside like a hospital nurse, said Amy Jeffries, an RN and nurse manager for Bunch CareSolutions, a unit of Xerox Corp. providing workers’ comp managed care services.
Injured workers are often scared and confused because they have never before suffered a work injury, so they don’t understand workers’ comp, Jeffries added.
“The biggest challenge is establishing a relationship by phone,” she said. “We don’t have that face-to-face contact so from the very beginning it is very important to work to establish trust.”
That requires following through with all promises.
“If you tell the injured worker, ‘I am going to call you back two days after your [medical] appointment,’ follow through and do that because by doing that, you establish that level of trust,” Jeffries said.
The same occurs when workers’ comp nurses provide face-to-face care for workers who have suffered previous workplace injuries, according to Mitchell.
“Initially, they are cautious with me,” she said.
“A lot of people, especially if they have had multiple work comp injuries and they have a history with it, look at me like I am representing the insurance company and I’m going to tell them they can’t have this [treatment] or we are not going to approve that [procedure].”
Mitchell is a case manager working under Travelers’ ConciergeCLAIM nurse program that places nurses in medical provider clinics treating injured workers.
She wins injured worker trust with assurances that she is their advocate and by following through with any promises, such as to obtain answers to questions she can’t immediately answer.
Margie Matsui, western nurse case manager for employer LSG Sky Chefs, said she carefully explains to injured workers why she asks specific questions about their injury, prior health conditions and issues such as their normal sleep pattern.
Explaining the reasons for her questions helps build trust while she learns whether she can teach them about measures for improving their health and whether there are medical complications that need addressing.
Challenges and Rewards
Nurses on the front lines also hear from frustrated injured workers venting about the work comp system or their injury status. But unlike bedside hospital nurses working with an unhappy patient for a few days, a case manager may interact with a disgruntled injured worker for months.
You can’t take negative attitudes personally, nurses advised. Do that, and you may not last in the job.
“You either love this [work], or you hate it,” Weaver said.
The work hours and less physically demanding roles are frequently cited reasons RNs leave a hospital to become a case manager, several sources said. Unlike hospital work, case management typically does not require weekends, nights or holidays.
They also apply their professional skill set in a different manner.
Where hospital nurses provide direct care, nurse case managers spend more time evaluating patients to determine whether they are progressing under their current treatment regimen, Weaver said.
That may require collaborating with a physical therapist, for example, to learn whether the patient is improving and whether their physician needs notification that a different program may be in order.
Nurses say they like the job because of the reward of seeing injured employees progress after working to get them the best medical care for their specific needs.
“There is nothing better than at the end of the file when you are getting ready to close it, looking back and seeing the progress that has been made,” Jeffries said.
Jeffries cited the example of a young worker whose hand got stuck in a piece of equipment, causing extensive nerve damage.
“With this particular gentleman, I didn’t leave my desk at the end of the day without thinking about him and thinking about how he was doing,” Jeffries said.
With the right care “he ended up doing very, very well” with very few limitations.
“It was definitely a success given the extent of his injuries in the beginning,” Jeffries said. “That is definitely one I was very proud of.”
Observers commonly think that telephonic nurse case managers may be less caring than hospital bedside nurses, but such experiences prove differently, Jeffries added.
Meanwhile, today’s nurses are under greater pressure to follow processes and protocols set by insurers, third-party administrators and employers, and they must show a return on investment from their services.
An employer may not immediately agree with a nurse’s care decision even when the decision is based on a professional opinion that spending additional dollars up-front for certain treatment could ultimately result in a speedier recovery, shorter claim duration, and fewer costs in the long run.
“Sometimes doing the right thing for the patient isn’t always seen as doing the right thing by the employer who pays for it all,” said Natalie Rivera, an RN and assistant vice president of clinical solutions at Bunch CareSolutions.
“It’s really balancing those two [demands],” she said. “Doing the right thing for the patient — if you do that, the rest falls into place. But sometimes it’s educating the employer on why this is the right thing to do.”
In addition to increased demands to reduce costs and follow processes, nurses now face medical cases that are more complex than in years past. Claims analytics currently help direct nurses only to patients likely to benefit from their services, but that means RNs will see a higher percentage of injured workers with complex claims.
There are also mandated state treatment guidelines that didn’t exist before, rapidly changing treatment practices, and increasingly complicated pharmaceutical regimens, Kirby said.
“It’s a level of complication that nurses just didn’t have to deal with before,” she added.
Yet that doesn’t change one key role for nurse case managers.
They work to drive collaboration so injured workers, employers, doctors, insurers, and physical therapists, among others, aim for the same goal, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company.
“Our job,” Thompson said, “is to say if this is our goal, and everyone is on the same page, then let’s keep our path real clear about how we are going to get there.”
Read the other installments of our three-part series on nurse case management:
Part I: On the Case
Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.
Part II: How Much Is Too Much?
Nurse case managers can provide vital consultation, but contractual limits to the expenses associated with the service are advisable.
A Modern Claims Philosophy: Proactive and Integrated
According to some experts, “The best claim is the one that never happens.”
But is that even remotely realistic?
Experienced risk professionals know that in the real world, claims and losses are inevitable. After all, it’s called Risk Management, not Risk Avoidance.
And while no one likes losses, there are rich lessons to be gleaned from the claims management process. Through careful tracking and analysis of losses, risk professionals spot gaps in their risk control programs and identify new or emerging risks.
Aspen Insurance embraces this philosophy by viewing the data and expertise of their claims operation as a valuable asset. Unlike more traditional carriers, Aspen Insurance integrates their claims professionals into all of their client work – from the initial risk assessment and underwriting process through ongoing risk management consulting and loss control.
This proactive and integrated approach results in meaningful reductions to the frequency and severity of client losses. But when the inevitable does happen, Aspen Insurance claims professionals utilize their established understanding of client risks and operations to produce some truly amazing solutions.
“I worked at several of the most well known and respected insurance companies in my many years as a claims executive. But few of them utilize an approach that is as innovative as Aspen Insurance,” said Stephen Perrella, senior vice president, casualty claims, at Aspen Insurance.
“We do a lot of trending and data analysis to provide as much information as possible to our clients. Our analytics can help clients improve upon their own risk management procedures.”
— Stephen Perrella, Senior Vice President, Casualty Claims, Aspen Insurance
Utilizing claims expertise to improve underwriting
Acting as adviser and advocate, Aspen integrates the entire process under a coverage coordinator who ensures that the underwriters, claims and insureds agree on consistent, clear definitions and protocols. With claims professionals involved in the initial account review and the development of form language, Aspen’s underwriters have a full sense of risks so they can provide more specific and meaningful coverage, and identify risks and exclusions that the underwriter might not consider during a routine underwriting process.
“Most insurers don’t ever want to talk about claims and underwriting in the same sentence,” said Perrella. “That archaic view can potentially hurt the insurance company as well as their business partners.”
Aspen Insurance considered a company working on a large bridge refurbishment project on the West Coast as a potential insured, posing the array of generally anticipated construction-related risks. During underwriting, its claims managers discovered there was a large oil storage facility underneath the bridge. If a worker didn’t properly tether his or her tools, or a piece of steel fell onto a tank and fractured it, the consequences would be severe. Shutting down a widely used waterway channel for an oil cleanup would be devastating. The business interruption claims alone would be astronomical.
“We narrowed the opportunity for possible claims that the underwriter was unaware existed at the outset,” said Perrella.
Risk management improved
Claims professionals help Aspen Insurance’s clients with their risk management programs. When data analysis reveals high numbers of claims in a particular area, Aspen readily shares that information with the client. The Aspen team then works with the client to determine if there are better ways to handle certain processes.
“We do a lot of trending and data analysis to provide as much information as possible to our clients,” said Perrella. “Our analytics can help clients improve upon their own risk management procedures.”
For a large restaurant-and-entertainment group with locations in New York and Las Vegas, Aspen’s consultative approach has been critical. After meeting with risk managers and using analytics to study trends in the client’s portfolio, Aspen learned that the sheer size and volume of customers at each location led to disparate profiles of patron injuries.
Specifically, the organization had a high number of glass-related incidents across its multiple venues. So Aspen’s claims and underwriting professionals helped the organization implement new reporting protocols and risk-prevention strategies that led to a significant drop in glass-related claims over the following two years. Where one location would experience a disproportionate level of security assault or slip & fall claims, the possible genesis for those claims was discussed with the insured and corrective steps explored in response. Aspen’s proactive management of the account and working relationship with its principals led the organization to make changes that not only lowered the company’s exposures, but also kept patrons safer.
World-class claims management
Despite expert planning and careful prevention, losses and claims are inevitable. With Aspen’s claims department involved from the earliest stages of risk assessment, the department has developed world-class claims-processing capability.
“When a claim does arrive, everyone knows exactly how to operate,” said Perrella. “By understanding the perspectives of both the underwriters and the actuaries, our claims folks have grown to be better business people.
“We have dramatically reduced the potential for any problematic communication breakdown between our claims team, broker and the client,” said Perrella.
A fire ripped through an office building rendering it unusable by its seven tenants. An investigation revealed that an employee of the client intentionally set the fire. The client had not purchased business interruption insurance, and instead only had coverage for the physical damage to the building.
The Aspen claims team researched a way to assist the client in filing a third-party claim through secondary insurance that covered the business interruption portion of the loss. The attention, knowledge and creativity of the claims team saved the client from possible insurmountable losses.
Modernize your carrier relationship
Aspen Insurance’s claims philosophy is a great example of how this carrier’s innovative perspective is redefining the underwriter-client relationship. Learn more about how Aspen Insurance can benefit your risk management program at http://www.aspen.co/insurance/.
Stephen Perrella, Senior Vice President, Casualty, can be reached at Stephen.email@example.com.
This article is provided for news and information purposes only and does not necessarily represent Aspen’s views and does constitute legal advice. This article reflects the opinion of the author at the time it was written taking into account market, regulatory and other conditions at the time of writing which may change over time. Aspen does not undertake a duty to update the article.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Aspen Insurance. The editorial staff of Risk & Insurance had no role in its preparation.