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.
Ask and You Receive
When consultant Barry Bloom of The bdb Group looked at his co-presenters on a panel on modeling managed care, he knew two things for sure. One, they operate in perhaps the toughest state in the country, and two, they may be among the best in the business.
Joining Bloom on the panel, presented at the 2014 National Workers’ Compensation and Disability Management Conference & Expo in Las Vegas, were John Smolk, principal manager, workers’ compensation, for Southern California Edison and John Riggs, manager of workers’ compensation for Disneyland.
In their workers’ compensation risk management, both Disney and Southern California Edison are large self-insured programs that care for thousands of employees.
Smolk and Riggs also share other characteristics. Both firmly believe in the importance of transparency in managing every aspect of their programs, from pharmacy benefits to medical providers and from claims adjustment to utilization review.
Whether a program is big or small, bundled or unbundled, transparency rules, the two said.
“I am big on transparency,” Riggs said.
“Transparency creates awareness,” Smolk seconded. “You need to make sure transparency is paramount.”
It’s an emerging theme in workers’ compensation risk management that you have to know who you are, what your philosophy is, and then be forceful and clear in communicating that to your employees and your risk management vendors and partners.
“It’s important that your program is well understood,” Riggs said.
In the complex world of medical management, that translates to being outspoken about what you expect from your service partners.
“If you don’t ask, you don’t get,” Riggs said.
Workers’ compensation risk managers also struggle with the concept of return on investment and its balance with quality of care.
Riggs, Smolk and Bloom cautioned that those who look for the lowest price in their medical services are not going to get the best quality of care; it’s just not going to happen.
“It’s not out there,” Bloom said.
What is practical and possible is achieving a balance between cost and quality of care — and here comes that word transparency again — creating medical provider networks, and where possible under state law, pharmacy benefit networks in which the goal of achieving that balance is ingrained.
It takes a lot of resources and energy to create a workers’ compensation program that knows what it is philosophically and communicates that philosophy.
Whether it’s the fees charged by the doctor or the sweat equity a risk manager has to put in to get great results, and ultimately lower costs, it’s not an easy road.
“There is a tremendous amount of effort that each one of us has to put into their programs,” Riggs said.
2015 General Liability Renewal Outlook
There was a time, not too long ago, when prices for general liability (GL) insurance would fluctuate significantly.
Prices would decrease as new markets offered additional capacity and wanted to gain a foothold by winning business with attractive rates. Conversely, prices could be driven higher by decreases in capacity — caused by either significant losses or departing markets.
This “insurance cycle” was driven mostly by market forces of supply and demand instead of the underlying cost of the risk. The result was unstable markets — challenging buyers, brokers and carriers.
However, as risk managers and their brokers work on 2015 renewals, they’ll undoubtedly recognize that prices are relatively stable. In fact, prices have been stable for the last several years in spite of many events and developments that might have caused fluctuations in the past.
Mark Moitoso discusses general liability pricing and the flattening of the insurance cycle.
Flattening the GL insurance cycle
Any discussion of today’s stable GL market has to start with data and analytics.
These powerful new capabilities offer deeper insight into trends and uncover new information about risks. As a result, buyers, brokers and insurers are increasingly mining data, monitoring trends and building in-house analytical staff.
“The increased focus on analytics is what’s kept pricing fairly stable in the casualty world,” said Mark Moitoso, executive vice president and general manager, National Accounts Casualty at Liberty Mutual Insurance.
With the increased use of analytics, all parties have a better understanding of trends and cost drivers. It’s made buyers, brokers and carriers much more sophisticated and helped pricing reflect actual risk and costs, rather than market cycle.
The stability of the GL market also reflects many new sources of capital that have entered the market over the past few years. In fact, today, there are roughly three times as many insurers competing for a GL risk than three years ago.
Unlike past fluctuations in capacity, this appears to be a fundamental shift in the competitive landscape.
“The current risk environment underscores the value of the insurer, broker and buyer getting together to figure out the exposures they have, and the best ways to manage them, through risk control, claims management and a strategic risk management program.”
— David Perez, executive vice president and general manager, Commercial Insurance Specialty, Liberty Mutual
Dynamic risks lurking
The proliferation of new insurance companies has not been matched by an influx of new underwriting talent.
The result is the potential dilution of existing talent, creating an opportunity for insurers and brokers with talent and expertise to add even greater value to buyers by helping them understand the new and continuing risks impacting GL.
And today’s business environment presents many of these risks:
- Mass torts and class-action lawsuits: Understanding complex cases, exhausting subrogation opportunities, and wrangling with multiple plaintiffs to settle a case requires significant expertise and skill.
- Medical cost inflation: A 2014 PricewaterhouseCoopers report predicts a medical cost inflation rate of 6.8 percent. That’s had an immediate impact in increasing loss costs per commercial auto claim and it will eventually extend to longer-tail casualty businesses like GL.
- Legal costs: Hourly rates as well as award and settlement costs are all increasing.
- Industry and geographic factors: A few examples include the energy sector struggling with growing auto losses and construction companies working in New York state contending with the antiquated New York Labor Law
David Perez outlines the risks general liability buyers and brokers currently face.
Managing GL costs in a flat market
While the flattening of the GL insurance cycle removes a key source of expense volatility for risk managers, emerging risks present many challenges.
With the stable market creating general price parity among insurers, it’s more important than ever to select underwriting partners based on their expertise, experience and claims handling record – in short, their ability to help better manage the total cost of GL.
And the key word is indeed “partners.”
“The current risk environment underscores the value of the insurer, broker and buyer getting together to figure out the exposures they have, and the best ways to manage them — through risk control, claims management and a strategic risk management program,” said David Perez, executive vice president and general manager, Commercial Insurance Specialty at Liberty Mutual.
While analytics and data are key drivers to the underwriting process, the complete picture of a company’s risk profile is never fully painted by numbers alone. This perspective is not universally understood and is a key differentiator between an experienced underwriter and a simple analyst.
“We have the ability to influence underwriting decisions based on experience with the customer, knowledge of that customer, and knowledge of how they handle their own risks — things that aren’t necessarily captured in the analytical environment,” said Moitoso.
Mark Moitoso suggests looking at GL spend like one would look at total cost of risk.
Several other factors are critical in choosing an insurance partner that can help manage the total cost of your GL program:
Clear, concise contracts: The policy contract language often determines the outcome of a GL case. Investing time up-front to strategically address risk transfer through contractual language can control GL claim costs.
“A lot of the efficacy we find in claims is driven by the clear intent that’s delivered by the policy,” said Perez.
Legal cost management: Two other key drivers of GL claim outcomes are settlement and trial. The best GL programs include sophisticated legal management approaches that aggressively contain legal costs while also maximizing success factors.
“Buyers and brokers must understand the value an insurer can provide in managing legal outcomes and spending,” noted Perez. “Explore if and how the insurer evaluates potential providers in light of the specific jurisdiction and injury; reviews legal bills; and offers data-driven tools that help negotiations by tracking the range of settlements for similar cases.”
David Perez on managing legal costs.
Specialized claims approach: Resolving claims quickly and fairly is best accomplished by knowledgeable professionals. Working with an insurer whose claims organization is comprised of professionals with deep expertise in specific industries or risk categories is vital.
“We have the ability to influence underwriting decisions based on experience with the customer, knowledge of that customer, and knowledge of how they handle their own risks, things that aren’t necessarily captured in the analytical environment.”
— Mark Moitoso, executive vice president and general manager, National Accounts Casualty, Liberty Mutual
“When a claim comes in the door, we assess the situation and determine whether it can be handled as a general claim, or whether it’s a complex case,” said Moitoso. “If it’s a complex case, we make sure it goes to the right professional who understands the industry segment and territory. Having that depth and ability to access so many points of expertise and institutional knowledge is a big differentiator for us.”
While the GL insurance market cycle appears to be flattening, basic risk management continues to be essential in managing total GL costs. Close partnership between buyer, broker and insurer is critical to identifying all the GL risks faced by a company and developing a strategic risk management program to effectively mitigate and manage them.
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.