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The skill level of the Nurse Case Manager (NCM) on your workers' compensation claims can have a major impact on the overall cost of your claims. In fact, I get more calls about "nurse case management" than about any other problem!
A NCM can be a valuable resource in getting the employee back to work promptly and insuring the employee makes the best recovery possible. Having the best NCM can save your company a ton of money, but the question becomes how do you get the best NCM on your work comp claims?! (WCxKit)
The approach taken by many risk managers, or the claims coordinator for the employer, in selection of the NCM is the old tried and true method history and experience. After the NCM has handled numerous claims for your company, you begin to recognize whether or not the NCM is doing a good job of medical management. This is an expensive way to learn who the good NCMs are. You have spent major dollars on numerous claims before you know for sure you have a great NCM or a lousy NCM. Some companies have "senior nurse reviewers" who have more expertise and experience than others.
Unfortunately some NCMs are reactive to medical developments and take a passive approach to the employee's overall recovery. These NCM can be, and should be, avoided. Like adjusters, the good and great NCMs have definite characteristics that set them apart from the rest. Recognizing the good NCM can be done before you have to spend major dollars on many claims. Some of the characteristics of a great NCM are:
1. Great interpersonal skills and organizational skills.
2. Having clinical expertise and experience with complex medical care issues.
3. A proactive approach to obtaining the most appropriate medical care for the employee while controlling the cost of the medical care.
4. A keen understanding of the financial aspects of medical care.
5. An ability to exercise independent judgment.
6. An ability to manage multiple priorities and activities in an unstructured environment.
7. A willingness to assist the employee to understand the medical treatment goals and expected outcomes of the treatment.
8. An ability to assess the employee's medical status by understanding the injury history, the medical treatment, the plan for future medical treatment and the overall recovery process, then combining this information to develop a case management plan and a return to work plan.
9. An ability to facilitate timely health care services with the minimal of lag time – maintaining continuity throughout the employee's recovery process.
10. An ability to act as a liaison between the employee, the employer, the medical provider and the workers' compensation adjuster.
11. A willingness to act as the employee's advocate with the employer, the medical provider and the insurer when necessary to achieve the quickest recovery for the employee.
12. An ability to work with the medical provider(s) to create the best treatment plan that will allow for the employee's timely return to work.
13. An ability to negotiate with both the employer and the medical provider to facilitate the employee's return to work on modified duty while accommodating the employee's limitation during the recovery process.
14. An ability to educate the employee to prevent a recurrence of the injury after the employee has returned to work full time.
15. A willingness to provide timely updates on the employee's progress to both the workers' compensation adjuster and the employer.
If you think you received a lot of push-back from the insurance carrier or the third party administrator (TPA) when you asked to select the adjuster for your insurance program, it was minor compare to the resistant you will get from the manager of the nurse case mangers for the insurer, TPA or outside vendor of medical case management services when you ask to select your NCM. The manager for the NCM unit will reassure you that all of his NCMs are professionals and they all have all the attributes listed above. While it is doubtful every NCM in the NCM unit will have all of these attributes, and even if they do, some NCMs will always do a better job than others – just like some adjusters are better than others, and some risk managers are better than others.
If you have already spent the money on many claims to learn which NCMs available to you are the best, then insist on excluding all but the top two or three NCMs. The insurer, TPA or independent vendor of medical case management will not want to lose your business and will accommodate your request (maybe begrudgingly). (WCxKit)
If your program is new to the insurer, TPA or outside vendor of case management services, ask the NCM unit manager for the names of current clients that you can contact for references. While you are checking the references, ask for the names of the top NCMs in the NCM unit. After you have identified the top two or three performers in the NCM unit, ask for only these top two or three performers to be assigned to your claims. Or, ask for Senior Nurse Reviewers. Again, the NCM manager will accommodate your request, maybe begrudgingly, but you will be happy with the money you save on your workers' compensation claims.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com
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SUBSCRIBE: Workers Comp Resource Center Newsletter
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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