The Ultimate Guide to Case Management
Everything a Claims Professional Needs to Know
As a claims professional, your days are busy and filled with many different tasks, sometimes making it hard to achieve the ultimate goal: successful claim resolution and closure. This page will provide you with an understanding of case management, why it’s important, and how it can help you resolve your claims. While case management is widely utilized throughout the property and casualty and health care industries, this page will focus primarily on case management in workers’ compensation. You will learn about the role and goal of the case manager, the type of services they perform, when to refer a case, how to measure the value of case management, and common governing bodies and credentialing organizations for case managers. You’ll be able to use this information to more effectively adjudicate your claims.
History of Case Management
One of the earliest references to case management dates to the late 1800s when it was utilized in settlement houses and charitable organizations to help coordinate resources with very limited access to health and human service systems. Immediately after World War II, the American Medical Association began viewing medical care as a three-phase process: prevention, cure, and rehabilitation. The concept of rehabilitation largely resulted from medical advances achieved in the treatment of wounded soldiers in World War II, who often required long-term medical management.
Fast forward to the 1970s when case management was introduced into Medicaid and Medicare projects, again to coordinate services for individuals in these distinct populations. At about this same time George T. Welch, a claims manager for the Insurance Company of North America (INA), developed a program of rehabilitation nursing intervention and a network of medical and vocational professionals as resource support. That same year, the Insurance Company of North America formed a subsidiary - International Rehabilitation Associates (IRA) to market professional rehabilitation services to insurance companies and other organizations. It was the first private rehabilitation medical cost-containment business in the United States. International Rehabilitation Associates was later acquired by Genex Services, LLC but the original idea lives on today – helping injured or ill individuals achieve optimal recovery and achieve their highest level of function.
“The greatest benefit a person can possess is the ability to work."
George T Welch
What is case management?
Case management is a clinical tool that has been used by claims professionals in the workers’ compensation industry for decades. But what actually is case management and what are the benefits of utilizing it as a claims management tool?
The most widely adopted definition for case management is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to facilitate an individual's and family's comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.” Case Management Society of America (CMSA).
Key components of the case management process include:
- Comprehensive assessment
- Case planning
- Coordination of care
Case management services many different populations and is utilized in many settings. However, regardless of where it’s used one common theme that is consistent throughout is the coordination of services.
To help better understand the role and the goal of case management, consider the following elaboration of a definition of case management from the Certified Case Manager Commission (CCMC):
- Case management is a “collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs.”
- The case management process is “characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.”
- Everyone benefits when our clients reach their “optimum level of wellness, self-management and functional capability.”
- “Case management services are optimized best if offered in a climate that allows direct communication among the case manager, the client, the payer, the primary care provider, and other service delivery professionals. The case manager can enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines.”
- Health care facilities
- State and Federal programs
- Health, disability, and casualty insurance
- Managed care companies
- Disease management companies
Benefits of Case Management
Now that we have established what case management is, let’s explore the benefits and understand why it is a vital tool for you as the claims professional, for the medical provider, the employer, and—most importantly—the injured employee.
Benefits to the Injured Employee
- Facilitates timely and appropriate coordination of care, taking the burden off the injured employee and family
- Educates the injured employee on all aspects of their care so that they can make informed decisions
- Helps the injured employee set reasonable expectations around recovery
- Provides support and advocacy throughout the process
Benefits to the Claim Professional
- Keeps the claims professional informed of all relevant medical and return-to-work plans and associated timeframes
- Decreases the dollars spent for both medical and indemnity payments
- Assists the claims professional in appropriate decision making
- Creates a positive working relationship between the claims professional, the injured employee, the employer, and the attorney (if involved)
- Provides an excellent resource for claim collaboration
Benefits to the Medical Provider
- Expedites coordination of treatment plan
- Facilitates communication between all involved
- Provides support and education to the injured employee, supplementing the treating provider
Benefits to the Employer
- Communicates return-to-work (RTW) goals and timeframes
- Helps identify transitional or modified duty
- Communicates essential job duties and associated physical demands to the provider
- Coordinates RTW between the employer and injured employee
In this section we will focus on case management delivery in workers’ compensation, review methods of delivery and the most common activities completed by case managers.
The National Institute of Occupational Safety and Health defines workers’ compensation as a system that provides partial medical care and income protection to employees who are injured or become ill from their job.
In general terms, the goal of case management in workers’ compensation is to coordinate medical care and assist the injured employee in returning to their highest level of function in a safe and timely manner. There is a great deal of activity that can occur between claim referral to case management and case closure, and it will vary from claim to claim depending on a number of variables including:
- Reason and timing of referral
- Diagnosis and treatment
- Return-to-work opportunities
- Psycho-social issues
- Comorbid conditions complicating recovery
Case management is delivered in two ways:
- Telephonically, typically referred to as telephonic case management (TCM)
- Face-to-face, typically referred to as field case management (FCM)
Both delivery systems can be effective but as a best practice, telephonic case management is used as an early intervention strategy, during the first 60 to 90 days post-injury or later in the claim to resolve a specific need. The idea being if you involve a TCM early in the claim they can help prevent it from becoming complex.
FCM is typically utilized on claims that are more complex in nature and need face-to-face intervention. Complex claims can be defined as a catastrophic injury/diagnosis or any claim that has complicating factors that may extend the disability duration or treatment beyond usual and customary guidelines.
Our expert team of over
2,000 Case Managers
facilitate timely & appropriate medical care and coordinate a safe and timely return-to-work.
- Comprehensive assessment of the injured employee’s injuries and illnesses as well as any comorbid conditions that may impact recovery
- Ongoing assessment of the injured employee’s progress toward maximum medical improvement and return to work
- Securing treatment and return-to-work plans from treating provider and comparing to nationally recognized guidelines
- Identification of non-medical barriers to recovery such as Social Determinants of Health (SDoH)
- Medical records retrieval, review and interpretation
- Review and assessment of medication regimen
Communication and Education
- Regularly scheduled contact with the injured employee to provide ongoing support throughout their recovery
- Injured employee education on treatment plans, expected recovery timeframes, the impact of comorbid conditions on recovery, and general health and wellness to improve mental and physical well-being
- Regular communication and collaboration with the claim’s professional (including providing periodic reports) regarding the employee’s progress and milestones achieved, such as maximum medical improvement or release to return to work (communication)
- Providing education to the injured employee regarding medication safety when warranted
Return to Work
- Coordination of return to work in a safe and timely manner, taking into consideration any restrictions or residual functional limitations and ensuring each plan is tailored to the individual’s needs
- Ensuring return-to-work planning is incorporated into the treatment plan and that expected recovery aligns with national guidelines
- Facilitation of return to work between the employer, injured employee and provider including job analysis, identification of transitional/modified duty or ergonomics assessments
- Assessment of and assistance with vocational needs when returning to work with the pre-injury employer is not possible
Coordination of Care
- Coordination of referrals to specialists and rehabilitation facilities as appropriate, channeling to network providers where jurisdictionally allowed
- Coordination of any transitions of care, transportation, home health care, durable medical equipment, therapy, home/vehicle modification, pain management, and other rehabilitative care services as needed
- Research and coordination of community resources and support
It is not unusual for a claim to have both TCM and FCM services. TCM and FCM can work hand in hand. Here are a couple of examples:
Example 1: TCM with FCM task
The telephonic case manager is having difficulty getting the treating provider to address return to work.
The telephonic case manager sends a task assignment to the local field case manager to complete a job analysis (JA) of the employee’s regular job duties and associated physical demands. The field case manager completes JA and forwards it to the telephonic case manager. The telephonic case manager shares the job analysis with the provider and obtains a return-to-work release.
Example 2: TCM transition to FCM
An injured employee’s diagnosis is complicated by psych-social issues identified by the telephonic case manager that will likely delay recovery.
The telephonic case manager recommends full assignment to the field case manager for ongoing face-to-face intervention with the injured employee and their care team.
We previously discussed the two types of case management delivery, telephonic and field, as well as the common activities performed by a case manager regardless of delivery type. In this section we will cover how to identify the need for case management.
How do You Know if Your Claim Will Benefit From Telephonic Case Management?
If your claims organization utilizes telephonic case management (TCM), there are two methods for identifying which claims could benefit:
- Automated risk identification
- Claims professional identifies a need
Data-driven risk identification utilizes claim data at the onset of the claim to identify claims that can benefit from early intervention. All claims are run through a risk model and trigger an alert when the claim is predicting risk, allowing for rapid assignment to a TCM for early intervention. As the claim matures, medical and pharmacy utilization data can be added to the risk model to enrich the information captured and surface claims that are exhibiting actual risk. Comparing medical and pharmacy data to nationally recognized clinical guidelines can easily reveal when treatment is trending in the wrong direction.
Not every claims program has access to automated risk identification. In that case, you must rely on your own claim expertise. Consider TCM if you are experiencing any of these situations:
- Injured employee is out of work
- Difficulty obtaining a return-to-work (RTW) release
- Complex medical treatments and/or multiple providers
- Provider is not providing treatment or RTW information
- Pharmacy concerns such as multiple medications, opioids >7 days, etc.
- Work restrictions are not progressing, or modified duty is going beyond the typical time frame
- Lack of progression in physical therapy
- Non-compliance with medical treatment
- One or more comorbid conditions exist, such as diabetes, obesity, and smoking
- Pre-existing injury to the same body part
- Surgery is recommended
- Complaints are inconsistent with the injury
- Diagnosis is unusual and not typical for a workers’ compensation claim
How do I Know if I Need Field Case Management?
Let’s start with the most urgent of field-based referrals, catastrophic case management.
Engage an experienced catastrophic case manager immediately upon notification of a potentially catastrophic claim. Getting a catastrophic case manager involved at the beginning of the claim:
- Conveys care and concern to the injured employee and family
- Ensures immediate understanding of the extent of the injury
- Assists you in early reserve setting
- Creates an open line of communication between all involved parties
- Allows the case manager to immediately establish communication with the treatment team and begin the transition of care planning
Examples of injuries considered catastrophic include:
- Severe eye injuries resulting in loss of vision
- Thermal or chemical burns
- Major burns
- Multiple injuries resulting in trauma
- Crushing injury/multiple fractures
- Electrical shock
- Spinal cord injury
- Acquired brain injury
Engaging a catastrophic case manager immediately is essential. Not only are the medical issues complex but the injured employee and family need support. They need assistance understanding their medical condition and treatment plan so that informed decisions can be made while navigating complex medical systems. Catastrophic injuries often require transition of care, long-term rehabilitation and discharge planning.
Discover two impactful case studies illustrating the transformative effects of case management on catastrophic claims.
Other Reasons to Consider Field Case Management
While catastrophic events are a clear indication of the need for field case management, there are also many other circumstances that can occur throughout the claims process that signal the need for field case management.
- There is a history of prior work-related injuries
- Pre-existing conditions exist that can impact treatment and recovery
- A pre-existing condition is aggravated
- There are multiple medical providers or frequent changes in providers
- The medical diagnosis does not align with the cause of the injury
- There is a conflict of medical status between the physician and the injured employee
- Medical treatment is anticipated to exceed usual and customary guidelines
- The employee is working light duty with no progression to regular duty
- Re-injury occurs shortly after return to work
- The employee does not believe they can or will ever return to work
- A job analysis is needed to identify essential job functions and associated physical demands
- Return to work will require job modification
- An ergonomic assessment is needed to modify the workstation
- The employer is unclear if the job is available for the injured employee to return to work
- There is no job for the employee to return to due to physical limitations
- The injured employee has limited education and skilled work history
- The injured employee has limited job-seeking skills
- A loss of earning capacity, wage earning capacity evaluation needed for settlement
Social Determinants of Health and Behavioral Health Concerns
- The injured employee is non-compliant with the treatment plan
- The injured employee misses, reschedules, or postpones appointments
- The employee expresses fear of re-injury
- There is a lack of transportation or other financial issues
- There is no family support or caregiver to support the injured employee
- The injured employee expresses feelings of depression or anxiety
There are many case management providers in the workers’ compensation marketplace ranging from sole practitioners to national providers.
But once you have identified the need for a case management referral, how do you select someone who will help you achieve the best outcome for your claim? And how do you determine if the vendor is qualified to provide case management services? Here are some questions you can ask when choosing a field case management provider.
The Top 10 Questions to Consider When Choosing a Case Management Partner
Does your case management partner:
- Offer national coverage with case managers in close proximity to the injured employee and the treating provider?
- Offer the expertise you need on your claim? For instance, are they trained in catastrophic case management, ergonomic evaluations or crisis intervention?
- Have bilingual case managers?
- Offer 24/7 catastrophic triage?
- Hold URAC accreditations that demonstrate their commitment to excellence?
- Employ case managers that are working towards or hold one or more national certifications?
- Utilize claim data to help you identify the need for clinical intervention?
- Promote advocacy for the injured employee?
- Engage your injured employee through interactive coaching and education?
- Offer data security to safeguard PHII, including SOC II Type 2 auditing?
Genex’s Case Management Capabilities and Expertise
URAC Accreditation–Demonstrating Commitment to Quality and Accountability
URAC is a non-profit charitable organization that establishes standards for the health care industry for health plans, pharmacies and provider organizations. URAC’s broad-based membership includes representation from all constituencies affected by health care, including employers, consumers, regulators, health care providers, and the workers’ compensation and managed care industries. Policymakers nationwide recognize the value of private accreditation in promoting cost efficiency and ensuring their constituencies receive quality health care. URAC’s mission is “To provide continuous improvement in the quality and efficiency of health care delivery by achieving a common understanding of excellence among purchasers, providers, and patients through the establishment of standards, programs of education and communication, and a process of accreditation.”
Genex has been accredited by URAC in Case Management in 1999. Holding a URAC accreditation:
- Demonstrates commitment to service quality and accountability
- Guarantees that policies and procedures are in practice that meet and exceed industry standards
- Designation of Excellence
- Assures compliance with state and federal laws, as well as managed care regulations
- Provides an alternative avenue for managed-care companies to demonstrate compliance with state and federal requirements
- If you would like to find out more about URAC accreditation, visit urac.org
Genex has been accredited by URAC in Case Management since 1999.
In the questions we outlined earlier in this section, we noted that your case management partner should hold an industry accreditation and their case managers should be working towards certification to demonstrate their commitment to excellence. But what certifications should you look for and what do they mean? Case managers typically hold one or more national certifications in addition to any required state licensure. Each governing board has standards of practice that the case manager must adhere to. There are many professional certifications.
The following is a list of URAC-recognized certifications:
- ACM, Accredited Case Manager
American Case Management Association
- CCM, Certified Case Manager
Commission for Case Manager Certification
- CDMS, Certified Disability Management Specialist
Certification of Disability Management Specialists Commission
- CMAC, Case Management Administrator, Certified
The Center for Case Management
- CMC, Case Management Certified
American Institute of Outcomes Care Management
- CRC, Certified Rehabilitation Counselor
Commission on Rehabilitation Counselor Certification
- CRRN, Certified Rehabilitation Registered Nurse
Association of Rehabilitation Nurses
- COHN, Certified Occupational Health Nurse
American Board for Occupational Health Nurses, Inc.
- COHN-S, Certified Occupational Health Nurse-Specialist
American Board for Occupational Health Nurses, Inc.
- RN-BC Registered Nurse Case Manager
American Nurses Credentialing Center
All the above‐mentioned credentials, as well as state nursing and state counselor licensing, contain a code of ethical behavior that the case manager must comply with in performing their job.
At Genex, we encourage our professional case managers to seek and obtain professional certifications based on their education, skill and background. Committed to quality and ethical casework, we hold ourselves accountable to a variety of quality standards. All CMSA standards of practice are followed, and all state/jurisdictional medical and vocational case management requirements are reviewed annually with all case management personnel.
What are Ethics?
Our industry and clients expect and demand that our case management staff will adhere to ethical standards of practice. These standards are reflected in the professional codes of conduct, codes of ethics and the various credentials and licenses our staff hold. Our business has become more dynamic as national case management certification and company accreditation has become a standard in our industry through URAC. Ethical standards within our various licenses, credentials and professional organizations have continued to evolve and change with the changes in our marketplace. This is an ongoing trend that is expected to evolve to meet marketplace demands.
Ethics are frequently defined as systematizing, defending, and recommending concepts of right and wrong behavior. These standards may have legal consequences for violating the code of ethics or standard of practice. Within the case management profession for both medical and vocational case managers, there are codes of ethics that define ethical behavior.
For case managers, there are also federal and state laws guiding the services we offer, the administrative processes we can implement to reduce costs or improve the quality of care, and the way we may interact with the ill/injured person, their provider, attorney, employer and our clients.
Now that you understand what to look for in a case management provider, we will explore how to make a referral to field case management.
It is important to note that telephonic case management is a service that is chosen and deployed by your employer based on criteria established between your employer and your telephonic case management provider. The information below pertains to how to place a referral for field case management services, which is often chosen at the discretion of the claims professional.
When making a referral, it is important to be as specific as possible in your referral instructions.
Things to consider: Task vs. Full Assignment
Field case management tasks are typically limited assignments where the case manager is asked to provide specific activities that can typically be accomplished in 30 days or less. For example, common medical tasks include:
- Attending the next physician visit to obtain a return-to-work release
- Obtaining an updated treatment plan
- Discussing medication utilization – review a pharmacy/drug utilization report with the treating provider
- Reviewing the job analysis with the treating provider
- Clarifying the injury causation with the treating provider
Other common tasks include:
- Obtaining a job analysis
- Assisting the employer in identifying transitional duty
- Assisting the employer in permanent job accommodation
- A vocational assessment
- A labor market survey
- An ergonomic assessment
- A home visit to assess the injured employee’s activities of daily living
- A medical cost projection or life care plan
Full case management assignments allow the case manager to manage the claim until the agreed-upon goal is achieved. The most common case management goals are:
- Return to work
- Maximum medical improvement
- Medical stability
As you can see from the information below, there are different types of field case management services and depending on the issues or questions you need addressed on a claim, you will want to let the field case manager know what service you wish to engage. The call-out below identifies the distinct types of common case management services.
Common Case Management Services
Medical and Return-to-Work (RTW) Services
- Medical tasks
- Medical management (no RTW)
- Medical and RTW management
- RTW tasks
- Job analysis/physical demands analysis
- Identification of transitional duty
- Catastrophic case management
- Crisis response
- Life care planning and cost projection services
- Legal/liability nurse reviews
- Ergonomic services
- Alternative transitional duty
- Vocational assessment
- Transferable skills analysis
- Labor market survey
- Job goal development
- Job-seeking skills training
- Job placement
- Document job availability and/or employability evaluation
- Rehabilitation plan development
- Educational assistance
- Earning capacity assessment
- Expert testimony
What Information is Needed to Make a Referral?
To place a referral, specific information is needed to begin including:
- Information about the injured or ill employee
- Claim number
- Date of injury
- Body part
- Employer information
- Provider information
- Attorney information (if applicable)
Please see the Genex FCM referral form for additional information.
How to Place a Referral
Genex offers several easy ways to place a field case management referral including phone, email, through Genex Case Connect, or by contacting your local Genex representative. Our central intake unit will take care of the rest. Check with your internal workflow for making referrals to FCM. Some clients have special portals or processes in place for making a referral.
What to Expect After Making a Referral
- A response from Genex confirming receipt of referral and name of the case manager assigned
- Outreach from the case manager via phone or email once they have the referral to introduce themselves and discuss the particulars of the claim and any special handling instructions
- Expect updates from your case manager after any significant contact or change in file status such as a doctor appointment, release to return to work, approval needed for recommended treatment, or actual return to work
- Written reports are sent in accordance with your company’s special handling instructions or if there are none, typically every 30 days following the initial assessment
Tips for Working with Your Case Manager
- Clearly state your reason for referral and any special handling needs
- Let the case manager know the best way to contact you - phone or email
- Best times to reach you by phone or email, including your time zone
- Return phone calls or emails to your case manager that require a response or approval as quickly as possible
The goal of case management is to make sure that the injured employee has access to appropriate, cost-effective, and timely health care resources to ensure the highest quality of care that will result in a timely recovery and return to their highest level of function. Let’s discuss how case managers document their impact upon case closure.
The goal of case management is to make sure that the injured employee has access to appropriate, cost-effective, and timely health care resources to ensure the highest quality of care that will result in a timely recovery and return to their highest level of function. Let’s discuss how case managers document their impact upon case closure. Since the birth of case management in the workers’ compensation industry, payers and employers have struggled to quantify the impact that case management has on a claim. Questions surrounding whether case management saves money on a claim, if savings calculations are real, and about return on investment (ROI) are often asked. Because case management is not transactional in nature like bill review and network services, case management cannot be quantified based on unit cost reductions at a point in time.
Case managers, like claims professionals, work with injured employees over a period of time, and their impact is best measured through claim outcomes.
There are varying methods for calculating savings at the claim or program level; however, most agree that savings should occur when medical and/or indemnity claim spend is reduced. Savings calculations at the claim level occur when medical services are decreased and/or negotiated and days off work are reduced. It is important to employ a sound methodology to demonstrate medical savings and lost time avoidance. These savings represent an “estimate” of potential savings associated with case management services and should be viewed as an early indicator that case management is making a positive impact on claims and a predictor of overall program outcomes.
Medical Cost Savings
Medical Cost Savings refer to those activities impacting the cost of medical treatment. The most common medical cost savings opportunities include:
- Negotiation of lower fees for health care services, equipment, supplies or medications
- Negotiation of an alternative level of care or treatment plan
- Prevention or termination of unnecessary treatment or services
- Reduction in the frequency or duration of a medical service
- Reduction in length of stay
- Utilization of alternative funding sources
- Identification of non-compensable treatment or services
Example: Physical Therapy (PT)
Provider requests three physical therapy visits per week for six weeks. Through frequent communication between the physical therapist and case manager, it was determined that the injured employee had reached maximum benefit from PT and could return to work after seven visits.
Initial request: 12 visits
The average cost per visit is $226.
Calculated savings 5 visits x $226:
Indemnity Savings calculations are typically based upon an ODG-driven methodology [click here to learn more about the Official Disability Guidelines (ODG)] embedded within the case management application. This system-driven approach provides the structure for the consistent application of guidelines that are derived from the distinct elements of the individual claim and care treatment plan input by case managers. ODG allows for accurate projections based on not only the primary diagnosis and treatment but also any confounding factors that may be impacting return to work (RTW).
Savings estimates are calculated by comparing the average duration (claim typical) set by ODG vs. the actual days of work missed by the injured employee. If the case manager facilitates return to work before the estimated RTW date, the difference between the actual and estimated RTW dates is multiplied by the wage replacement benefit amount to calculate savings.
The case manager facilitated care and coordinated RTW
15 Days Earlier
than the average length of disability as defined by ODG.
The impact of case management on a claim goes well beyond financial and should be viewed in terms of whether the life of the injured employee was improved and if there was a positive financial effect. When asked, “how did you impact a claim?” most case managers would not lead with a monetary response.
In simplest terms, case managers help injured employees return to work, play and life by facilitating timely, appropriate care and supporting them throughout their recovery, leading to better claim outcomes that result in a financial return on investment.
It is important to remember, helping people and improving financial outcomes are not mutually exclusive. Take care of the injured employee and great outcomes will follow.
Now that you’ve learned the basics of case management, here are some resources to provide a more in-depth look at case management: