Improve Medical Case Management in Workers' Comp Claims

There are countless opportunities to bring savings to your workers’ compensation program. One such option is a review of your program’s medical management processes for handling claims. By taking action now, your program can make better decisions in the coming months and ensure dollars are correctly spent when it comes to claims.

What is Medical Case Management in Workers’ Compensation

Medical care management is a process that involves the review of treatment plans for injured employees to make sure they are receiving the proper medical care and treatment for their work injury. This collaborative process includes reviewing what the employee is receiving and considering the coordination of health care and can consist of family members and expected results. The goal is to get the employee back to their pre-injury condition and not require additional medical care in the long term.

Critical aspects of medical case management include:

• Patient intake and immediate post-injury medical care;

• Overall management from acute treatment phase through maximum medical improvement. It can include the involvement of a nurse case manager and review and use of proper prescription drug regimens;

• Overall supervision when the employee is using opioid-based prescription medications; and

• Other medical review tools such as independent medical examinations, peer review, and utilization reviews.

Now is the time to conduct a review of your processes and make the necessary changes.

Indicators of a Great Medical Case Management Program

Like anything in the insurance industry, the signs of an effective medical case management program are driven by data-based metrics. Areas interested stakeholders should review should include:

• The overall duration of medical care and treatment and wage loss: It is essential to members of the claims management team to provide all medical care that is reasonable and necessary, which allows the employee to return to work. Metrics should be established for various types of injuries and the need for medical care.

• Employee morale: Claims teams should work with their insureds on improving workplace morale for all employees. This includes employees who have not suffered a work injury. When employees see everyone being treated fairly, workplace morale increases.

• Cost of the Medicare Set-aside: Future medical care cost projections that include Medicare reimbursable items and services have become a mainstay in every workers’ compensation program. Interested stakeholders should be proactive on this issue, and avoiding overfunding allocation amounts. 

• Ability to drive claims toward settlement: The only good file is a closed file. Members of the claim management team should be looking for opportunities to resolve open workers’ compensation cases promptly. This should include a constant review of files that can be settled and taking the necessary steps to resolve those claims.

The goal of the above factors it to only spend on required actions when managing claims. Signs of an effective medical case management program include returning an employee to work without the need for prolonged medical care.

It is All About the Outcome

Everyone in a workers’ compensation claim is interested in the outcome. For the injured employee, it is the need to get back to work. Employers are hurt when people are out of work – their bottom line impacts. The claim management team wants closure.

Effective medical case management allows all parties to achieve this goal. Opportunities to achieve these goals can include the development of the following:

• Medical Provider Network: Allows employees to receive immediate and proper medical care and treatment. Networks allow employers, and insurers to better manage costs of the care.

• Nurse Case Management: There are many challenges to navigating medical care following a work injury. Trained nurses can assist employees with questions and are on call 24 hours a day.

• Utilization Review: Treatment modalities such as physical therapy, chiropractic care, surgeries, and extended hospitalization drive up costs. This process can spot potential red flags and assist the claims team in making better decisions.

Many other services can be included in this area of case management. Failure to use them will only drive up workers’ compensation program costs.

Conclusions

Medical case management provides opportunities for claim management teams to reduce workers’ compensation costs. Now is the time to review your management program and determine its effectiveness and what changes can be made to make sure every dollar is best spent.

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