Workers' Compensation

The Balancing Act of Rehabbing Injured Workers

The demanding task of nurse case management grows ever more complicated.
By: | December 10, 2014 • 7 min read
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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.

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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.”

Claims-Payer Representatives

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.

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“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.

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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.

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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:

10152014_04_indepth_series_nurse_150x150Part I: On the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.

11012014_09_indepth_150x150Part 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.

Roberto Ceniceros is senior editor at Risk & Insurance® and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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2014 NWC&DC

Ask and You Receive

Communication and transparency rule when it comes to managed care programs.
By: | November 21, 2014 • 2 min read
Managed Care

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.

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“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.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at dreynolds@lrp.com.
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Sponsored: Healthcare Solutions

Diversifying Top Management in Workers’ Comp

Inaugural Women in Workers’ Compensation (WiWC) Forum focuses on advancing more women into top leadership roles.
By: | January 7, 2015 • 5 min read

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The panel at the inaugural Women in Workers’ Compensation (WiWC) Forum. From left to right: Eileen Ramallo, Elaine Vega, Nina Smith-Garmon, Nancy Hamlet, Michelle Weatherson, Nanette de la Torre, Danielle Lisenbey.

Across the country, the business community is engaged in a robust conversation about women being under-represented among c-level positions.

Why aren’t more women breaking into upper management roles? Does gender bias still exist? And, perhaps more importantly, what can women and men do to add more diversity to top leadership ranks?

Elaine Vega and Nancy Hamlet, of Healthcare Solutions, the Duluth, Ga.-based health services provider to the workers’ compensation and auto liability/PIP markets, have discussed the issue between themselves many times over the years.

The duo agreed that starting an industry-wide conversation would be an effective start to addressing the challenge. After three years of internal discussions, the inaugural Women in Workers’ Compensation (WiWC) Forum became reality. Judging by the attendance, content and feedback, it was an auspicious, very successful, debut.

Nancy Hamlet, Senior Vice President of Marketing, Healthcare Solutions

Nancy Hamlet, Senior Vice President of Marketing, Healthcare Solutions

Specifically, Healthcare Solutions and LRP Publications teamed up at the National Workers’ compensation and Disability Conference (NWCDC), held Nov. 18-21, 2014 in Las Vegas, to present the first WiWC event focused on the development of women as leaders within the industry. The WiWC debut featured a keynote speaker, a panel discussion and a networking cocktail hour.

“We believe this is just the beginning for the WiWC organization,” said Hamlet, senior vice president of marketing, adding that the event’s main theme was the conversation regarding challenges that still exist for women in the workplace is “current, real … and relevant.”

Originally the forum was allocated a room to hold 150 people. Vega and Hamlet worried about the room being too large, so they asked LRP what the contingency would be to make the room smaller if they couldn’t fill it. They needn’t have worried, as more than 400 women, and some men as well, registered and attended, requiring an even larger room.

“Clearly, the topic is relevant and there was plenty to discuss,” said Vega, senior vice president of account management.

Hamlet explained that WiWC was formed to create an open forum to promote a strong sense of community and support for current and future female leaders in the workers’ compensation industry. Going forward, the WiWC forum will provide insight and ideas with opportunities for members to:

  • Engage … with accomplished industry professionals and build lasting relationships.
  • Enrich … their knowledge base with tactical insights from speakers and panelists.
  • Explore … opportunities and challenges facing women leaders today.
  • Encounter … senior executives’ perspectives on leadership.
  • Examine … leadership strategies and how to effectively apply the strategies.
  • Empower … themselves and others to achieve success and groundbreaking results.

At the inaugural event, keynote speaker Peggy Holtman, co-author of “Leading at the Edge: Leadership Lessons from the Extraordinary Saga of Shackleton’s Antarctic Expedition,” discussed how a seemingly unconnected historical event can offer critical lessons on leadership in the workplace, especially for women looking to move into top executive spots.

Elaine Vega, Senior Vice President of Account Management, Healthcare Solutions

Elaine Vega, Senior Vice President of Account Management, Healthcare Solutions

After Holtman’s talk, a panel discussion, moderated by Vega, offered the perspectives of five workers’ compensation industry executives on ways in which women can navigate past the glass ceiling. Panelists included Eileen Ramallo , EVP Healthcare Solutions; Danielle Lisenbey, CEO Broadspire; Nanette de la Torre, VP Zenith; Nina Smith-Garmon, EVP Mitchell International; and Michelle Weatherson, Director, Claims Medical and Regulatory Division, State Fund of Calif.

The panelists discussed a wide range of topics related to women in workers’ compensation. For example, one topic focused on the need to take the big risks when it comes to moving past workplace barriers. Other topics included the importance of women in higher positions serving as sponsors and advocates for younger, less experienced women; and the impact of industry consolidation on women’s careers and how to best manage that change. Another topic was how women could best master conflict and emotions in the workplace.

“What’s clear is conflict has to be managed; it will not go away. It will only get worse,” said Healthcare Solutions’ Ramallo. “It then can create other rifts that won’t necessarily be visible immediately, but can have a very large impact. You have to be able to understand what it is early on from another’s perspective, why the situation exists, and then encourage and try to resolve a conflict situation, whatever may be driving it.”

In the wake of the first WiWC Forum, Hamlet noted that while there are countless general reports showing that women have not yet achieved equal representation in top leadership positions in the workplace, studies deal with averages rather than individual stories. And while women must continue to look at the data and work toward closing the gap, hearing from accomplished women in the workers’ compensation industry at NWCDC drove home critical messages on a person level.

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Today, Vega and Hamlet are looking to expand WiWC to make it “truly owned” by the industry. For example, they expect to recruit companies interested in becoming sponsors, forming an advisory council, creating a charter and discussing future possibilities for the organization on both the national and regional levels.

“Much remains to be done, but I have confidence that we will come together and make the organization stronger so that it prospers for years to come,” Hamlet said. “After all, it’s clear that our industry is filled with talented women who can make things happen!”

Vega added that WiWC has already received requests to live stream the event in the future, so it will examine the feasibility of that option in an effort to be even more inclusive.

“We have a shared vision for improving opportunities for current and future women leaders in workers’ compensation,” Vega said. “It doesn’t matter our gender or our title, it’s all about supporting the greater vision. As was said several times at the event, this is just the beginning. We hope more women and men will join us in this continued dialogue.”

For more information about the WiWC, send email to wiwcleadership@healthcaresolutions.com or join our WiWC group on LinkedIn.

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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 Healthcare Solutions. The editorial staff of Risk & Insurance had no role in its preparation.




Healthcare Solutions serves as a health services company delivering integrated solutions to the property and casualty markets, specializing in workers’ compensation and auto liability/PIP.
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