How to Use Case Management to Improve Claims Outcomes

    Strategic Use of Case Management

    Case management is at the heart of workers’ compensation

    Workers’ compensation case managers are committed to changing lives for the better and devoting themselves to the welfare of those committed to their care. At Genex, case managers coordinate the entire continuum of care for injured workers, from injury through return to work. They are responsible for assessing, planning, coordinating, implementing, and evaluating injured employees through the medical case management process.

    They work as intermediaries between carriers, attorneys, medical care providers, employers and employees to ensure appropriate and cost-effective health care services. A large claims analysis shows that more than half of injured employees referred to nurse case management are back to work within three months, which is significantly higher than those who did not receive case management. Delays in case management intervention quickly lengthen return to work as much as 50 percent and cost payers over 30 percent more.

    When is case management appropriate?

    Claims should be evaluated for case management intervention when:

    • There are multiple physicians involved in one claim
    • The claimant has a history of previous injuries
    • Guidelines for return to work are nearing and there is no indication of the worker returning to his/her job
    • Treatment exceeds and/or falls outside of evidence-based guidelines
    • If injury involves a major joint that limits movement and/or functional ability
    • A catastrophic event occurs which results in burns, crushes, amputations, or paralysis (immediate on-location attention from field case managers)
    • Patient’s psychosocial status needs to be assessed. For example, does the employee live alone? Does he/she have a history of depression or is he/she on antidepressants?

    Field case management

    Expediting recovery for severe or high-cost injuries

    Depending on the case, direct case management may expedite an injured worker's recovery and return to work. Field case managers typically are assigned to more severe or high-cost injuries, often at the discretion of the claims professional. The manager may go to the injury site, visit the worker at the hospital, and accompany him to medical appointments. Situations indicating referral to a field case manager include any severe injury, such as injuries to the eyes, brain, spinal cord or those resulting in loss of consciousness. Also, any injury involving chemical or electrical burns, traumatic amputation or any claims involving inpatient or outpatient surgery benefit from hands-on field case management.

    Examples of injuries that benefit from field case management intervention:

    • Severe eye injuries involving visual acuity changes or loss
    • Severe brain or closed head injury with loss of consciousness
    • Spinal cord injury or crushing injuries
    • 2nd- and 3rd-degree burns (>30 percent body) including chemical or electrical
    • Stress or psychiatric claims
    • Traumatic amputations of the hand, foot, arm or leg
    • Any injury resulting in paralysis or coma

    Transparent oversight in managing these claims results in better outcomes and reduces delays in return to work. For example, take the case of a police department aide who had been diagnosed with reflex sympathetic dystrophy (RSD) of the ankle five weeks earlier. Despite staying compliant with her treatment, the worker’s condition was deteriorating. When the field case manager reviewed a photo of the injury site, the case manager noticed the injured worker had developed cellulitis in her lower extremity. She immediately instructed the injured worker to seek emergency care. It was soon determined that the woman had developed non-work-related deep vein thrombosis, a serious clotting condition. The case manager’s quick actions allowed the woman to receive treatment just before the condition became systemic and potentially life-threatening. Through the case manager’s efforts, the injured worker returned to work full duty with no restrictions and has reached maximum medical improvement with no impairment rating.

    Catastrophic case management

    Giving workers with the worst injuries the best possible recovery

    Catastrophic claims represent less than 1 percent of all workers’ comp injuries, yet some studies show they account for up to 20 percent of costs. Catastrophic injury costs can range from $500,000 to $5 million or more. The most serious injuries — spinal cord injuries, severe burns, amputations, multiple traumas, traumatic brain injuries — are disasters that disrupt lives and present significant financial risk. Injured employees, their families and employers may be uncertain how to react or where to turn. That’s where catastrophic case management can play a key role.

    Seriously injured employees recover to their maximum potential — medically and functionally — and return to the most productive lifestyle when a specialized program is in place. Catastrophic nurse case managers are trained to provide the kind of support and guidance patients and their families need throughout the treatment and recovery process. Their fast, on-site intervention helps assure the course of treatment follows guidelines and that appropriate local resources are used to support case goals. Add to that a comprehensive national network of physician specialists who can be consulted at any time and centers of excellence experienced in working with catastrophic injuries. The result is a team offering best strategies for the worst workplace injuries including medically sound, cost-effective patient treatment recommendations that positively impact outcomes.

    Telephonic case management

    Keeping cases within specified guidelines

    The key to successful workers’ comp return-to-work strategies is keeping a case within industry and internal guidelines. While most companies have return-to-work guidelines for specific injuries that automatically require case management, it’s important to note that case management may also be warranted when the prescribed treatment falls outside of, or exceeds, evidence-based guidelines with no functional improvement.

    An imperative tool to help keep cases within guidelines is telephonic case management. Proactive workers’ comp programs get case managers involved from the day of injury, or as early as possible, and is most effective when used within 12 days of the injury. Other times, case managers are assigned cases when injured workers are forced to miss work due to their injuries. The telephonic case manager facilitates the return-to-work protocol, either in a modified capacity or full duty. Telephonic case managers are an invaluable resource in determining current medical status, managing claims with extensive diagnostic testing or imaging, working with claimants who have more than four weeks of physical therapy or chiropractic care, or managing any claim that has prolonged or questionable treatments.

    Some examples of claims that significantly benefit from telephonic case management include:

    • Early investigation to determine medical status
    • Claims with extensive diagnostic tests/imaging
    • Claims with extended physical therapy or chiropractic care (longer than 4 weeks)
    • Employees who are on modified duty for longer than 1 week
    • Severe lacerations of tendons, ligaments or muscles
    • Prolonged or questionable treatments

    One example of impactful telephonic case management is the claim in which an injured worker sustained serious 2nd- and 3rd-degree burns to his right arm, face and head. Attentive care for this type of injury is crucial for healing and infection prevention, so the telephonic case manager referenced guidelines such as ODG to assess the treatment plan, including pain management and medication protocols. The case manager was persistent with continuous follow up, assuring the injured worker was compliant with treatment, while also making certain his medical concerns were addressed. Despite a safe and efficient healing process, the worker was initially reluctant to go back to work because of reinjury concerns. The case manager worked with him to ensure the employer had developed a modified duty job that would allow him to return to his job in a safe manner. Through excellent teaching and aggressive case management services, the injured employee had an early and safe return to work four months ahead of schedule.

    Getting your case management program off autopilot

    Without a magic formula to flag low-cost cases that will evolve into complex, costly claims, you need a strategic case management program that keeps treatment on track and prevents costs from spiraling out of control. Industry experience shows that 85 percent of claims resolve within guidelines, 10 percent need additional intervention and 5 percent develop into long-term, chronic claims that can cost millions; those are the claims that must be addressed. Equally alarming is the uncertain costs that carriers and employers accrue for delayed referrals to case management.

    A recent analysis of claims for several large employers and carriers by Genex Services showed the company’s case management programs improved RTW rates by 35 percent over WCRI standards. When case management is viewed as a strategic tool, rather than a commodity, your team is empowered to identify and intervene on claims before they begin to be excessive. This begins with a thorough understanding of when, where and for what types of injuries case management involvement is appropriate. Payers and employers have improved the efficiency, effectiveness and total cost of risk by taking an in-depth look into their program and reviewing considerations that can move a program from a static commodity to a strategic tool.

    Is Case Management a Commodity?

    The Commodity Myth

    Unfortunately, there is a concern among employers and carriers that often case management is brought in too early or for claims for which there is little value. As a result, some in the industry have a perception that case management is “just a commodity” without quantitative differentiation across vendors. Perhaps this is one of the reasons that, despite its proven value, use of nurse case management remains low, especially early in the claim cycle. Only about 10 percent of all U.S. workers’ comp claims today use nurse case managers.

    In truth, the effectiveness of a case management program hinges on the outcomes the case management provider can produce.

    While virtually any vendor can provide commodity-level case management, what employers and carriers need are business partners that can quantify their value and ability to achieve better ROI and faster RTW through advanced data analytics, including segmenting outcomes based on trigger diagnosis or code to find ways to improve program performance. A true partner will turn data into action and will provide high-quality services quickly and efficiently at a reasonable cost.

    When you work with a managed care provider that develops a customized approach to case management intervention, claims achieve better and more cost-effective outcomes than a low-cost commodity bidder.

    Implementing a scientific approach

    A strategic case management organization uses evidence-based medicine, analytics and internal data to better identify the tipping point of a claim that is beginning to spiral.

    For example, research has shown the effect of delays in case management intervention on return to work. An analysis of a large set of complex claims clearly demonstrated that the longer the delay in intervention, the higher the costs and the longer it takes to return employees to their jobs. The findings indicated that the first 0-30 days following injury is a critical window for identifying referral indicators, citing claims that utilize case management within 0-3 months of the injury are twice as likely to achieve a successful return to work than those that are referred 3-12 months after the injury. For each month that passes from time of injury to referral, there is a steady drop in the return-to-work rate. Additionally, the RTW rate can drop to nearly 20 percentage points when delaying a year to refer.

    Strategic case management programs have intervention strategies in place to identify claims that are at risk for delayed recovery early in the process. There are many formalized tools for identification such as the OMSQ and other questionnaires used to predict risk of delayed recovery or potential for chronic symptoms. However, even without a formal questionnaire, case managers are able to assess risk as a component of their initial and ongoing injured worker assessments to deliver the right treatment at the right time resulting in the best possible outcome for the claim.

    Using Analytics to Impact Outcomes

    Using data to improve claims decisions

    Analytics and data can play a critical role in helping organizations identify when to strategically use case management, providing facts that become the foundation of sound policies. Analytics alone do not change behavior or drive program success but, if when woven into your claims operation, yield actionable information from which to make better claims decisions.

    As information is gathered in the claims process, data analytics can help reveal the trajectory of a case. The more information collected and assessed through the life of the claim, the better a data model can predict where a case is headed. For this to happen, however, all appropriate data elements must come together — claims, bill review, utilization review, case management, and pharmacy benefits — to develop a complete picture. Data points across an organization’s claims tell a story about the program as a whole, helping risk managers view the big picture in terms of trends in high-cost and problematic areas.

    With this type of intelligence, you can begin to design a medical management approach that can change the course of individual cases to achieve better outcomes and contain costs. Specifically, data analytics can impact workers’ compensation case management performance by detecting spiraling claims that will likely cause excess costs and delays in return to work. Identifying these claims before they go completely off the rails empowers you to intervene earlier and bring the risky claim back on track. During the claim, data can be used to assess case severity, arming the claims handler and the case manager with information on the appropriate treatment needed to achieve an optimal outcome.

    Workers’ compensation payers and employers reap the benefits when data, subjective and objective measures of performance and machine learning come together to drive more strategic use of case management and overall improvement of claims outcomes. For example, when you work with a strategic partner, data analytics is used to evaluate treating providers. Using this information, the claim is matched with the right provider based on quantitative and qualitative data, contributing to lower costs saved on unnecessary treatments and a better outcome for the injured employee.

    Moving from a static to dynamic case management program

    With costs, outcomes, compliance, and even public perception on the line, many organizations need a targeted and more dynamic approach to the administration and reporting of case management.

    Effective programs allow for flexibility so that rules and decisions can be measured, monitored, and refined to provide true insight, guidance, and actionable information. Your case management program should include the ability to:

    • Provide configurable clinical and business rules that support customization and rapid deployment of changes in rule design and enforcement
    • Utilize algorithms to show when and how to use clinical interventions
    • Integrate with claims, medical bill review, and pharmacy management data streams to identify problems in utilization, such as narcotics and physical therapy
    • Identify under- or over-utilization of case management
    • Provide guidance on where and when to use telephonic case management, field case management, utilization review and physician advisor services
    • Measure the nature and effectiveness of the human decisions made in every case

    A dynamic case management program should use a combination of data, experience, and best practices to yield better outcomes and gain more control over costs. Creation of a sound case management program begins with a close examination of where the program is today, and scrutinizing what works and what does not.

    Managing Trends and Regulations

    Staying compliant with changing regulations

    Despite its century-old history, workers’ compensation is an ever-evolving, complex system, that is highly regulated and open to litigation. Each state regulating its own program further complicates the system. As specialists with training specifically in workers’ comp, nurse case managers can help provide guidance when working with injured employees, physicians or providers who are unfamiliar with their state’s rules and regulations or the most effective return-to-work guidelines.

    Systems that utilize case managers who are specially trained and experienced in managing workers’ compensation claims play a large role in maintaining regulatory compliance and avoiding possible litigation. These include case managers who hold appropriate certifications, following industry-driven/state-mandated/URAC-compliant case-handling guidelines, or any other special handling protocols that provide oversight and structure to the case management process.

    There is no substitute for on-site interaction with your workforce. When claims happen, these programs have dedicated field case managers to assist the employees so that the best clinical outcome can be achieved and litigation can be avoided. One of the contributing reasons that claims go to litigation is that adjusters are overloaded with work and have limited time to communicate with injured workers, which causes stress and feelings that the payers are not looking out for their best interest. In fact, a Washington state survey found that only 15 percent of adjusters communicated with injured employees and employers within 30 days from receiving a claim.

    Complicated processes involved in workers’ compensation are another reason injured employees seek legal assistance. Without a dedicated advocate to help the injured worker navigate the system, some turn to attorneys to ensure they are getting the care they need. A key part of the case manager’s job is to educate the injured employee and empower him/her toward recovery.

    Curtailing the opioid epidemic

    Prescription opioid misuse is a major problem in the United States, costing $78.5 billion each year for health care costs, lost productivity, addiction treatment and criminal justice involvement. Around 21 to 29 percent of patients prescribed opioids end up misusing them and, of these, 4 to 6 percent transition to heroin abuse.

    In workers’ compensation, opioids make up a third of all prescribed pain relief drugs and account for 20 percent of the total claim spend. One of our industry's most available resources to influence opioid use is the nurse case manager. Case management intervention plays a significant role in limiting opioid abuse including:

    • Ensuring medication safety across the care continuum
    • Enforcing greater compliance with medication usage
    • Improving education and communication with all parties
    • Reducing or decreasing inappropriate drug utilization
    • Delivering peer review documentation of medical necessity
    • Improving patient outcomes

    In fact, it’s becoming more evident that case management is the missing link in successful opioid management and weaning programs. Case management intervention is especially effective after a comprehensive pharmacy review (CPR) has taken place. This is when a pharmacist or peer physician has conducted an evidence-based peer review of prescriptions and the prescriber’s treatment plan. The CPR includes recommendations to modify the drug therapy — and will typically include weaning or tapering. However, if the pharmacist or peer physician is unable to reach an agreement with the provider — or the provider agrees, but does not implement the changes, the case is referred for case management review.

    In these cases, the case manager arranges an onsite visit with the prescriber. The case manager will take the peer review report, sit down with the prescriber to review the recommendations, and come to an agreement on the treatment plan. The modified plan might include anything from developing strategies to facilitate weaning, tapering or discontinuation of one or more narcotics to recommendation of supportive therapies, such as physical therapy, aquatic therapy, cognitive behavior training, home exercise, home stretching program, biofeedback therapy, and work hardening.

    In 57.3 percent of the case management drug intervention cases, the prescriber agrees to all or part of the modifications. In many cases, the physical presence of a nurse in the prescribing doctor's office makes a positive impact.

    Genex works with customers to address long-term problem cases, but one of our main goals is to also engage customers on a more proactive basis, where case managers are helping identify narcotic risk factors from day one. This includes a detailed medication assessment, where case managers look for risk factors that could signal the injured worker is at risk for opioid addiction. If these issues are addressed early, it can go a long way in preventing dependency and addiction from occurring in the first place.

    For more information

    Workers’ compensation case managers are committed to changing lives for the better and devoting themselves to the welfare of those committed to their care. When case managers are called on early in the claim, they can drastically expedite return to work and cut down on claim costs. To see how your program could benefit from case management intervention, click here to schedule a free expert consultation, and see how case management can be used to drive a dynamic program to optimize claims outcomes.