Addressing Provider Shortages in Workers’ Compensation Settings 

Case Management Focus

The workers' compensation system is complex and challenging for many physicians to navigate. This leads to many physicians refusing to treat injured workers. As a result, many states are faced with shortages of adequate physicians and specialists to evaluate and treat injured workers. Physician shortages result in delays in care, excessive lost time, additional stress for both the employer and the employee, and challenges for the claims adjustor, who must meet deadlines on each case.  

In this article, I outline some of the challenges physicians face and how having a nurse case manager involved can help providers gain a new perspective on working in the area of workers' compensation. 

• Excessive paperwork: Workers' comp cases require detailed documentation based on state regulations and insurance mandates. Many providers find this challenging and time-consuming. In my experience, what has worked for providers who are successful in this area of practice is to add a staff member dedicated to handling workers' compensation clients. As staff members become familiar with the rules and regulations required of providers, they can better organize themselves and keep up with the necessary paperwork after each visit. Nurse case managers who work with these offices build relationships with the staff and can address issues and expedite the required paperwork so that diagnostic tests and other services are completed promptly. 

• Delayed payments: Insurance companies often take a long time to reimburse providers. This can be challenging for small practices who are trying to manage their cash flow. When working on a case with a new provider, the nurse case manager informs the provider's office of the documentation the adjustor needs to pay the bill promptly. If there are payment delays, the nurse case manager works with the claims adjustor and providers to identify and resolve issues, allowing for timely payment. This gives the provider an advocate who can help them overcome barriers and get their fees paid promptly. 

• Approval for Involvement of Services: The nurse case manager ensures that the claims adjustor has the necessary information to approve the provider's requested services. Once approval is given, the nurse case manager will work to set up appointments or find resources that the doctor wants the injured worker to have. Follow-up appointments will be scheduled for the physician to re-evaluate the injured worker, allowing for adjustments to the plan of care as needed.  

• Nurse Case Managers work as advocates for providers and liaisons with claims adjustors to address issues and resolve conflicts promptly. Nurse case managers understand the system – they know who to go to in order to get things done.  
• Legal complications: Many providers are reluctant to work in the area of workers’ compensation as they do not want to be drawn into litigation. Having a nurse case manager on the file can help manage the expectations of the injured worker, making them more realistic. The nurse case manager is in place to advocate for the injured worker and ensure they receive what they need when they need it, at the right time, and in the least restrictive environment. This helps the injured worker feel heard and cared for. Attorneys are usually called in when the injured worker does not feel valued and does not trust the system. Having a nurse case manager involved in the case who will listen and move the case along can help decrease the need for an attorney.
• Building Provider Networks: Nurse case managers are natural networkers and can help organizations expand their networks with the necessary providers who have the expertise to care for the injured worker based on their area of practice. Put feelers out to your case management teams and watch your networks grow! 

If you are experiencing shortages in your provider networks, I hope these tips will help you and your organization find providers who can meet the needs of your injured workman population.

If you have questions or would like to suggest a topic for a future post, please email Anne Llewellyn at allewellyn48@gmail.com 

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