Filed Under:Risk Management, Public Sector Risk

6 best practices for case managers

To ensure every claim is handled with compassion, case managers need to focus on these six best practices.(Photo/Shutterstock)
To ensure every claim is handled with compassion, case managers need to focus on these six best practices.(Photo/Shutterstock)

There's a troubling misperception in the Workers' Compensation industry that must be addressed. Case managers, adjusters and those involved in settling injury claims have one mandate: To cut costs no matter what.

At Genex Services, we want to help employers and insurers ensure optimal use of case managers and control costs. The misperception is our blind adherence to cost-cutting, rather than our humanity and compassion toward injured workers. Most in our industry work diligently to balance appropriate use of case managers, return to work and management of costs for the benefit of all parties.

Misperceptions regarding our industry are especially prevalent with regard to case management. Recent media accounts appear to show a lack of caring about the plight of injured workers.

But what is reality? On a daily basis when caring, experienced case managers engage with injured workers, who are often in the midst of frightening and stressful situations, it isn't just business name, date of injury and looking at treatment guidelines, limits and denials. There is much more to case management today. Case managers know that to do their job well, they must become advocates and champions for the injured worker. That kind of relationship builds trust, which leads to better engagement, adherence to care plans and, ultimately, outcomes.

Saving a young man's leg
I see what really happens in case management on a daily basis. Some dramatic, touching, yet typical stories come to mind. In one, a worker was involved in a serious forklift accident, severely damaging his heel. The ankle became contracted, and an orthopedist said the worker needed a below-the-knee amputation. As a relatively young man, the worker didn't want that, but he didn't know where to turn or what to do. His case manager stepped in to advocate for him, speaking to physicians and researching alternatives. The case manager helped identify a physician who suggested a new advanced surgical procedure and a fixator device that helps stabilize severe foot and leg injuries after surgery, would correct the contracted ankle.

After successful surgery followed by weeks using the device and physical therapy, the worker was able to walk again. It wasn't an easy process. In addition to finding treatment alternatives, the case manager had to make a strong case to the insurance company to receive approval for a relatively new procedure.

Understanding the clinical value, and because the case manager had earned the company's trust from past experiences, the insurer agreed. Soon after completion of physical therapy, the worker underwent a functional capacity evaluation, which demonstrated his ability to return to modified work duty.

By hearing the concerns and fears of the worker, the case manager not only saved a leg and returned a young man to his activities of daily living, but also helped the employer manage costs. According to the Official Disability Guidelines, costs for surgery, fixator and therapy were approximately $33,000, whereas the cost for amputation would have been approximately $81,000. A medical savings of approximately $48,000 was realized by avoiding amputation, not to mention potential savings of the cost of the prosthesis and perhaps longer delays in returning to work.

Holding case management providers to high standards
To make sure every claim is handled with compassion, we need to focus on the following best practices, while considering what is best for the employee (which, as it has been shown time and again, is best for employers and payers as well):

  • Ensure case managers are specially trained and experienced in managing Workers' Compensation claims, including holding 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.
  • Use case managers strategically for claims. Case managers can play a role in more than just standard catastrophic claims. Studies show claims that effectively use case managers improve return to work by 25% as compared with Workers' Comp Research Institute standards. Consider using case managers for historically challenging injuries (such as back and shoulder) and involving them in pharmaceuticals to ensure the appropriateness and safety of both narcotic and non-narcotic medications.
  • Educate employees to help them understand the role and goal of case managers, as well as their own role in the medical treatment plan, and share with them stories of how other employees have been helped. Case managers are the conduit liaison between the employer, injured worker and the medical providers ensuring continuity of care.
  • Conduct surveys of the program to gain insight from case managers and identify problems or concerns. If there are problems or concerns, address them immediately with your vendor.
  • Look for a vendor who will partner with you. Cost isn't the No. 1 factor — best RTW rates and superior outcome are.
  • Hold your vendor to the highest standards of care, compassion and outcomes.

Changing perceptions regarding our industry won't happen overnight. There is much to gain from optimal Workers' Comp programs: True support and compassion for injured workers; better care and outcomes; and safe and appropriate return to work. But this won't happen unless those of us in the Workers’ Compensation industry work together to share the reality of who we are as businesses, people and an industry. It’s time for our industry to tell the real story of what happens in Workers' Comp today.

Related: 7 Workers' Comp issues to watch

Tim Howard is senior vice president for field case management at Wayne, Pa.-based Genex Services.

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