Case Management Focus: Working Together, We Can Do Better!

Sarasota, FL (WorkersCompensation.com) -- Workers’ Compensation claims have always been a litigious area. Why? As noted in an article titled Breaking the Cycle of Litigation in Workers Compensation from Insurance Through Leadership, there are many reasons. Here are eight points that I found lead to litigation: 

1. Insurance company denied claims. 

2. Insurance company denied treatment. 

3. Injured workers were afraid they wouldn't get their needs met (mostly referencing necessary care or financial impact). 

4. Injured worker was afraid they would lose their job. 5. Injured workers needed help figuring out how to get what they needed. 

6. Friend/coworker told the worker they needed to get an attorney after being injured. 

7. Lack of communication from carrier/employer/TPA. 

8. Overbearing communication from carrier/employer/TPA. 

Looking at the list, the first two seem obvious. People don't want to be told no —and feel they are being slighted if a claim or treatment is denied. Beyond denials of claims, there are battles over compensability and reasonable, necessary care. The others point to mistrust, fear, anxiety, and loss of control in a fragmented, complex system and not user-friendly. 

Granted, there are legitimate reasons for an injured worker to retain an attorney in a workers' compensation case. But attorney involvement is often sought because the injured worker does not trust the system. The downside of unnecessary attorney involvement is that it raises the cost of the claim and does not benefit the injured worker. 

Statistics show that attorneys are involved in 5 to 10 percent of all workers' compensation claims in most states—but in as much as 20 percent in systems where the number of disputes is high and in roughly a third of claims where the worker was seriously injured

Attorney involvement heavily impacts indemnity costs which are 3.5 times higher than claims without an attorney. A 2022 report from Milliman Nodal bears this out, claims with attorney representation take 2.1 times longer to close and cost 2.3 times more than claims without an attorney. Given the impact of attorney involvement, it's critical to identify these claims to control costs and manage cycle times. 

In addition to the increased cost of the workers' compensation claim, the injured worker does not make out as expected. Many times, they lose more than they gain, unfortunately. They may get a small settlement, but what do they give up for this? 

Case management can mitigate the issues that cause someone to seek an attorney when injured on the job. Here are some ways a case manager can help address the problems that arise and allow the claim to move forward. 

Case managers listen to injured workers and encourage them to ask questions when they have them. This helps return to them their sense of dignity and autonomy. 

Case managers work to improve communication between the injured worker, the healthcare team, the adjustor, and the employer. 

Case managers are advocates for the injured worker and the family and help them understand how the system works so that expectations are managed. 

Case managers work with the treatment team and gather information on why a treatment, therapy, or procedure should be done. They can help the adjustor understand the need and seek a second option if needed. 

When a treatment/procedure is denied, the case manager works with the injured worker to seek other solutions that address their individual needs.

The case manager works with the employer and the injured worker to look at return-to-work options. Doing so helps the injured worker to see progress and helps them financially as they can get regular pay while still getting treatment vs. the workers' comp fee schedule that each state must follow. 

When an attorney is involved in a case, the case manager can work with the attorney to understand their goals and help to resolve conflicts that can delay the case and raise costs. There are many times I have worked with the plaintiff's attorney, and together we moved the case along to a be a win-win for both sides. 

A study by Zurich showed that when nurses are engaged early, the result can be an average of $6,000-$26,000 total savings per claim, with nearly 50% of those savings in medical spending.

As a nurse case manager, I work with injured workers to help them get medical care to reach their maximum potential and return to gainful employment. 

In the end, all stakeholders must keep their eye on the goal; to help the injured worker get the treatment they need to address their workplace injury and return to gainful employment. When we work together for the same goal, we can achieve outcomes that benefit everyone.  

References: 

Insurance Thought Leadership: Breaking the Cycle of Litigation in Workers: https://www.insurancethoughtleadership.com/commercial-lines/breaking-cycle-litigation-wc 

Insurance Information Institute: Spotlight on Workers Compensation. https://www.iii.org/article/spotlight-on-workers-compensation#:~:text=Overall%2C%20attorneys%20are%20involved%20in,the%20worker%20was%20injured%20seriously. 

Milliman Nodal: How does attorney involvement Impact a Claim? https://nodal.milliman.com/en/insight/How-does-attorney-involvement-impact-workers-compensation-claims 

Zurich: Claims Case Study: Early Nurse Referral can result in savings. https://www.zurichna.com/knowledge/articles/2016/09/claims-case-study-early-nurse-referral-can-result 

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