Claims Management Focus Shifting to Medical Side for Best Practices
"I think part of the driver is the shift in total overall spend for workers' comp claims over the last several years from indemnity to medical management," said Denise Algire, a New Mexico-based registered nurse and the practice leader of Integrated Health & Productivity Management for the Risk Navigation Group. "Insurers and self-insureds are saying, 'what can we do to be the best in class.'"
For Algire and others in risk management, it means identifying and implementing best practices in medical management. First and foremost is eliminating silos.
"When we talk about medical management, the key is an integrated approach," Algire said, "having medical case management and claims examiners working hand in glove in the claims management process."
Getting nurses involved early in the process is also crucial, said Lisa Holcomb, vice president of medical management for Zenith Insurance Co. One of the most important roles of nurse case managers is developing rapport and educating the injured worker.
"If they've got a comorbid condition -- smoking, for example, and the physician recommends surgery. The individual needs to stop smoking or lose weight before surgery," Holcomb said. "It's educating the injured worker about those pieces."
It is also important to have the right triggers for nurse case management engagement. "By implementing the right file with the right resource at the right time you will make sure you are managing that case proactively. It is too late once that request comes in for spinal surgery," Holcomb said.
Integrated model: an example. Using integration processes to handle claims involves everything from pharmacy benefit managers to nurse case managers and utilization review. "Various programs have to be integrated. They can't operate in silos or you lose traction in terms of getting efficiencies," Algire said.
It also provides a whole-picture view of the injured worker, which can lead to better outcomes, Holcomb explained. "The national medical guidelines might state additional physical therapy is not needed but if you are looking at the case as a whole you might approve the additional physical therapy because you know that this will lead to return to work or functional restoration for the injured worker."
Developing the best integrated model for your company starts with focusing on the desired outcomes -- reverse engineering of your operational model. The outcomes should be measurable.
As an example, Algire elaborated on the idea of a company seeking to reduce its pharmacy costs. First, she would find out where the company ultimately wanted to be and focus on the specific parts of medical management programs to get it there. Then she would show others in the claims process how to take the programs in silos and integrate them, so all the information would be shared among them.
"You can have a wonderful pharmacy program, but if the information is not shared or integrated into the claims system, it's not getting to the people making the decisions to control the costs," Algire said.
Partnering with an effective PBM or other pharmacy management program is vital. "A key is to look for a pharmacy partner that will have both outcomes measures and a clinical model that helps them control and manage provider behavior," she said.
For example, if the use and misuse of opioids is problematic, it's important to have clinical management programs in place from a medical case management standpoint and pharmacy standpoint. "Make sure you partner with providers that have the tools in place," Algire said. "Most providers that handle chronic pain have medication refill contracts with injured workers to control the use [of opioids]. It is critical that you partner with providers who address and segment the personal, occupational, and social factors from the outset." Identifying the right providers is crucial to the process.
To ensure best practices are achieving the desired goals, Holcomb suggests having measurements in place, including the use of self-audits to determine whether best practices are being followed by medical case managers.
"It is not enough to develop and implement best practices you have to evaluate if the best practices are being executed and you can measure them," Holcomb said.
Additional best practices.
Other strategies for holding down medical costs include:
- Early identification of claims with lost time.
- Early and continuous communication with the injured worker, provider, and employer is also fundamental to facilitate the treatment and RTW plans. "A lot of companies complete the three-point contact early on, but then stop communicating within a few months," Algire said. "A lot can happen during that period of time."
- Expediting medical care. "The often used, old approach of managing and controlling medical care to control costs is not an effective strategy," Algire said. "If the injured worker needs an MRI, facilitate that early on. Otherwise, you delay the treatment and extend the claims cycle."
Read more at the WorkersComp Forum homepage.
December 20, 2010
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