Tag Archives: Nurse Case Management

A How-To on Nurse Case Management

Nurse case management (NCM) has a powerful impact on workers’ compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, but widespread evidence of nurse impact has not emerged, and objective proof of value is still missing. Several factors account for this.

Inconsistent Referrals

For one thing, NCMs are usually considered an adjunct to the claims process, called upon in sticky situations. Too often, referrals to nurses is a last resort rather than an integral and standardized part of claim management. When claims adjusters have the sole responsibility to refer to NCMs, it can be subjective, uneven and therefore unmeasurable.

Besides receiving referrals for sundry issues at different points in the course of the claim, nurses have not clearly articulated their case management interventions. Claims adjusters sometimes misunderstand the nurses’ approach. However, consistent referrals and standardized procedures can bring about major change.

Consistent referrals

Referrals to NCM should be made based on specific medical conditions in claims such as comorbidity like diabetes or problematic injuries like low back strains that tend to morph into complexity and high cost. Specific risky situations found in claims data should automatically trigger NCM notification.

A recent article published in Business Insurance, “Nurses a linchpin in reducing workers’ comp costs,” points out how Liberty Mutual has developed a tool that notifies claims adjusters of cases that would most benefit from a nurse’s involvement. Decision burdens for claims adjusters are eliminated. Referrals to NCM are automatic based on specific high-risk situations found in the claim. Inconsistency disappears, and several benefits evolve from this approach.

Process standardization

An operational process can be dissected and categorized, thereby gaining better understanding of its components and relative importance. Review the data to determine which medical conditions in claims result in longer disability, lower rates of return to work and, of course, higher costs. Select the conditions in claims that should activate an NCM referral.

An example is a mental health diagnosis appearing in the data well into the claim process. A mental health diagnosis appearing during the claim for a physical injury such as a low back strain is a strong indicator of trouble. The injured worker is not progressing toward recovery. However, the only way to know this diagnosis has occurred in a claim is to electronically monitor claims on a continuous basis.

Data monitoring

To identify problematic medical situations in claims and intervene early enough to affect outcome, the data should be monitored continually. Clearly, this is an electronic, not a human function. When the data in a claim matches a select indicator, an automatic notice is sent to the appropriate person.

Standardized procedures

Catching high-risk conditions in claims is just the first step. NCM procedures must be established to guide responses to each situation triggered. Standardized procedures should describe what the NCM should evaluate and advise possible interventions. Such processes not only explain the NCM contribution, they assist in documentation and are the basis for defining value.

Measuring value

NCM has been under-appreciated in the industry because measuring apples-to-apples cost benefit has been impractical. When claims adjusters decide about referring to NCMs and individual nurses create their own methodology, variables are endless and little is measurable.

In contrast to the subjective approach, specific conditions in claims found through continuous data monitoring can automatically trigger a referral to the NCM. In response, the nurse is guided by the standard procedures of the organization. When referrals are based on specific conditions in claims and response procedures are delineated, outcomes can be analyzed and objectively scored.

Did the Work Comp Nurse Make It Worse?

Case management nurses can unwittingly hinder the control of workers’ comp claims. Consider the perfect storm of “assumptions” leading to disaster: An adjuster receives a claim requiring extended treatment, makes the standard screen-clicks to assign a nurse and logs the claim in the diary. The employer assumes the case is being scrutinized and treatment is being managed. The adjuster assumes it is okay to ignore the case for a while. The nurse takes the initial claim information at something approaching face value.

In these situations, many nurses act but don’t interact. They assist with referrals and expedite the collection of medical information. Unfortunately, they may not use their clinical acumen on critical issues like compensability, diagnosis, causal relationship, return to work (RTW) and treatment plans. We should note that nurses must balance caseloads and respect their company’s requirements for speed. As such, they might feel justified in expediting what appears to be a common assignment.

When it comes to referrals, a well-intentioned nurse can cause disaster. I have experienced all of the following: a claimant alleging breathing issues referred to a “sick building expert”; a claimant with negligible head trauma to a “closed head injury specialist”; a claimant alleging jaw pain to a “TMJ dentist”; and the ever popular referral of a claimant with mysterious pains to a “chronic pain specialist.”

These real examples all involved highly questionable claimants. Needless to say, medical expert “hammers” saw perfect “nails” in each claimant and fully validated the conditions and the causal relationship each alleged. By the time of the next adjuster diary, it was all over but for the increase in reserves.

The claimant can steal control of a case and contrive subjective medical issues if a nurse simply collects doctor reports and fails to interact. Countless WC case files exist where medical notes are simply pasted in by the nurse. (As far as I am concerned, this indicates adjuster/employer failure and not necessarily a poor nurse.)

I have witnessed nurse case managers decline to intervene in RTW efforts, and the corporate nurse care management entity can, conveniently, relieve itself of RTW responsibilities without affecting its fixed fee. I would argue that some level of RTW support from a nurse can and should exist on any given case in any jurisdiction.

Quick Tip: You and Your Adjuster Must Engage and Direct Nurse Assignments

A nurse should be vital in selecting providers for specialist evaluation or independent medical exams (IMEs). However, the nurse needs the insight and outlook that can only be gained by communication and planning. Engage the nurse and explain all the case issues and concerns. Compare providers and agree on who might be most appropriate. Agree on the specific background, insight and questions to be given to this provider. An early conference call should be mandatory.

The nurse should be an active member of the claim team, including adjuster, employer, defense counsel, Medicare medical savings account (MSA) vendor and, in certain cases, the special investigative unit (SIU). Nurse contributions should be vital to team decisions and strategy.

Make certain the nurse case management fee-structure allows extended work, as a claim might require. Reconfigure if necessary to ensure nurses can spend adequate time where needed.

A nurse should be asked to evaluate, comment and make suggestions based on all medical info collected. This insight can be used by the team to make tactical and strategic decisions.

A nurse is most useful for assessing the claimant on a personal level. The nurse should be sought for oral comment on impressions and gut feelings based on interaction with the claimant. Written assessments, which are subject to discovery in legal proceedings, need to be subtle and are not as meaningful. Therefore, conference calls on an interim basis are critical for gaining powerful nurse insight.

Nurses should absolutely support RTW efforts, either at most by collecting potential jobs from the employer and sharing these directly with the employee and doctor or at minimum by reminding the doctor that the employer has a RTW program and expects participation. Somewhere along this range of support should fit any jurisdiction.

Nurses are great tactical tools against unwieldy claimants. They can relay important details and extraneous issues to a physician that can affect causation determinations and reliability assessment of subjective symptoms. Nurses give doctors an “option B” of facts and background when doctors otherwise would only consider “option A,” as relayed by a claimant. Without an “option B,” doctors are more likely to give a claimant benefit of the doubt.

Most important: The power of case management nurses is wasted if you do not provide specific insight, direction and expectation for each claim assigned.