The competence of nurse case managers can make or break a workers’ compensation claim. On one hand, direct interaction between a nurse and an injured worker can improve claims outcomes.

On the other, there is the risk that a profusion of nursing business models is confusing payers, leading to cost overruns and nurses staying on a case past the point where they can provide meaningful or cost-effective consultation.

Under pressure to show buyers that they provide value, nursing service vendors wield predictive modeling, medical guidelines and case criteria for triggering nurse interventions among other resources that help limit nurse deployment only to those services that will aid a client’s claim.

Payers can also help cap excessive nursing expenses with client instructions that dictate when telephonic nurse case managers will be assigned to assist injured workers and how long those nurses will play a role, said Thomas Ryan, workers’ compensation market research leader at Marsh.

“That is just another way to make sure it doesn’t become too costly because in auditing, sometimes you see that a nurse case manager has been on a claim for so long that it is actually the cost driver on that particular claim file,” Ryan said. That no longer happens as often as in the past, however.

“There are controls in place now so that doesn’t happen as often,” Ryan added. “But there are those [cases] that go off the chart.”

Years ago, case management could linger without results, said Ronald J. Skrocki, VP, product management and development at GENEX Services Inc. Now payers demand action plans outlining how long case managers will be involved and what their goals are.

Among the wide range of nursing services available today, three tend to be the most common:

• Triage nurses taking telephone calls from injured workers or their supervisors 24/7 when an injury first occurs to help determine whether additional medical attention is necessary.

• Telephonic case management nurses that may work side-by-side with adjusters to help resolve ongoing claims.

• Field case managers for the most challenging medical cases.

Payers commonly contract for a blend of those services, said Gregory Stevens, VP of nurse case management at CorVel, a third-party administrator.

The blend is often customized to meet specific buyer’s needs and the three services are typically integrated so that claims pass from one of the nurse offerings to the next, depending on the injured worker’s medical needs.

For the triage nurses available by phone around the clock, payers typically pay about $75 to $80 per incidence, Ryan said. That includes the nurse taking the initial call and then follow-up calls. Those prices can vary depending upon contract negotiations and the volume of calls a payer’s employee population generates, he added. A flat rate is typical for telephonic case managers with the rate dependent on whether nurses will be assigned, for example, to cases for 30 days or 60 days. The volume of services a payer will demand also impacts negotiated prices.

Field case management charges are generally based on “time and expense” with, say, an hourly rate for travel time and wait times while doctors examine patients, Ryan said.

There are also a variety of methods for delivering different workers’ comp nursing services.

In April, for example, The Travelers Cos. Inc. announced it would expand a ConciergeCLAIM Nurse program to new locations across the country. The program places the insurer’s nurses in medical provider clinics to review diagnoses and help injured workers with their treatment plans. This comes after a pilot program showed the program reduced return-to-work durations, increased use of network medical providers, and decreased employer costs.

Return on Investment

Many experts agree that calculating a precise return on investment from nurse utilization is elusive. How do you measure what would have happened on a claim had a nurse not been assigned?

Additionally, when employer workers’ comp programs rely on multiple measures to improve claims outcomes, it’s virtually impossible to isolate the precise contribution of nurse case management.

“If someone could figure out a way to concisely and accurately show financial value, they would be so far ahead of everybody else,” said Patrick Walsh, VP and chief claims officer at Accident Fund Holdings Inc. Yet, “intuitively, it’s a pretty easy leap to say there is value in this.”

“You can’t expect adjusters … to be able to effectively manage the medical component of very complex injuries where a nurse, or other medical professional, has a skill set designed to do that. You are kidding yourself if you think there is no value.”

“If someone could figure out a way to concisely and accurately show financial value, they would be so far ahead of everybody else.” — Patrick Walsh, VP and chief claims officer, Accident Fund Holdings Inc.

But payers do press nursing service providers to show results, several experts said.

“The problem is there is no standard in the industry on how to capture savings,” CorVel’s Stevens said. “The only way that we can tell we are doing a good job, or if anybody else is doing a good job, is [by answering the question] ‘Are we decreasing your total claims costs?’ ”

That requires analyzing historic and ongoing claims data to evaluate how all the services the TPA provides for a client account are impacting a client’s claims outcomes or total cost of risk.

Savings can also be estimated through nurse documentation of their specific impact on a claim, such as an unnecessary surgery a doctor initially recommended but then decided against, following a nurse’s questioning of their treatment plan, Ryan said.

To control costs while determining which claims are most likely to benefit from their services, nurse service providers rely on a variety of measures, including predictive analytics, coupled with medical treatment guidelines and alerts that trigger nurse involvement when a claim meets certain criteria.

“There is a lot of predictive modeling being offered by the carriers and the TPAs,” Marsh’s Ryan said.

“That gives them insight. Based on certain conditions early on in the claim cycle they can see which claims meet this criteria and have the potential to become high dollar claims. So they want to get a nurse early to reduce the threat of medical complications or additional medical spend.”

Stewardship meetings and other personal interaction also help service providers and payers determine the best mix of nursing products for clients, experts said.

Clients or potential clients may have their own criteria for using nurses and they sometimes pose requests for deploying nursing resources that are not likely to improve their specific claims experience, said Veronica Cressman, VP, medical programs for ESIS, a third-party administrator and unit of ACE Ltd.

“There are clients who may want them on every case and we have learned to look at our data to tell us which cases would really benefit from having nurses.” — Veronica Cressman, VP medical programs, ESIS

For instance, an employer might ask for telephonic nurses on every case, which is something ESIS does not recommend, Cressman said.

Such requests require probing to learn the client’s specific claims environment to learn why they believe the extensive service is necessary and whether they might achieve their desired outcomes without paying for so many nurses, she added.

“We want to make sure we use clinical resources appropriately and are cognizant of how much the client is spending. So we have identified our criteria for which cases might warrant telephonic case management,” Cressman said.

“There are clients who may want them on every case and we have learned to look at our data to tell us which cases would really benefit from having nurses.”

There are also significant challenges to hiring nurses to provide a wide range of nursing services, such as marshaling the resources necessary to license them across 50 states.

“That is a very tedious process and a very expensive process, so a lot of companies have chosen not to go that route,” CorVel’s Stevens said.

Large payers who contract for nurses say, however, that they enforce their own guidelines and standards for how nurses are to provide their services.

Regardless of how nursing services are delivered, the goals remain the same. They include helping advocate for injured workers, coordinating their care, and reviewing doctor treatment plans with an eye to producing results that get workers back to functionality without excess medical spending.

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Read 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.

Part III: Available in the December 2014 issue.