For the past few years, workers' compensation has experienced a general decline in claims frequency. The bad news is that frequency may soon flatten out and could begin to rise. This shift may significantly exacerbate the challenges claims professionals already face in workers' compensation. For example, although it is understood that prompt reporting of injuries leads to improved claims outcomes, there are still many barriers to achieving this best practice.

Medical costs continue to rise at double-digit rates, and as a result, now comprise approximately 60 percent of the average claim. Indemnity costs are also problematic. Even though organizations have spent considerable time and resources to facilitate return-to-work (RTW) programs, these initiatives have failed to yield optimal outcomes. Within this current state of flux, many organizations are looking to implement innovative strategies to overcome traditional hurdles, but what is new in workers' compensation?    

What is Injury Triage?
Recently, a new trend has emerged, wherein employers are turning to nurse call centers to perform injury intake, thereby enabling timely, accurate reporting, while also triaging injuries to the most appropriate level of care. Triage is the process during which medical professionals assess and assign a degree of urgency to a wound or illness. Triage has predominantly been used in the ER to determine the order in which patients should be treated, especially when there is a limited number of medical staff available. Today, a telephonic form of the process has evolved, leading to the growing popularity of nurse call centers.

Health plans first began to provide plan members with access to toll-free nurse hotlines so that patients could call to obtain medical advice when they were unsure of where to turn for treatment. These nurse hotlines have played a critical role in triaging cases to the most appropriate level of care, as well as providing self-care guidelines for minor medical conditions. As a result, health plans have ensured proper utilization of healthcare services while saving significant costs.

The workers' compensation industry is just beginning to catch on to this concept, leveraging nurse triage to reap similar benefits and savings. By using a workers' compensation hotline, employees can speak to a nurse within minutes of an injury occurring. A triage nurse is then able to make critical medical decisions that can positively impact the patient's care, as well as claims costs and outcomes.

An injury hotline represents a departure from the traditional role nurses have played in workers' compensation. Typically, nurses served as case managers, coordinating care for only the most complex and severe injuries. Today, triage nurses can get involved at the front end of each and every workers' compensation claim—essentially at the “point of injury”—to assist employees in obtaining the right level of care from quality, cost-effective providers.

Prompt Reporting, Lower Claims Costs
Since The Hartford Financial Group's groundbreaking study, it has become common knowledge that prompt reporting of injuries leads to improved claims costs and outcomes. However, there are still many obstacles to compliance. For example, an injured employee may wait until an injury worsens and requires serious medical attention, or supervisors may be delayed in filing the proper claim forms.

As a result, injuries are sometimes reported as long as five to 10 days after an incident has occurred. This means that employers miss a valuable window of opportunity to manage the injury and are then forced to play “catch up” to regain control over the claim's direction. Even when claims are reported on time, they often contain incomplete information, which hinders effective claims investigation.

Injury triage provides an opportunity to simplify the process: the employee or supervisor calls the toll-free hotline to report an injury. Triage nurses are trained to gather comprehensive injury information. The hotline handles all of the required paperwork, reducing or eliminating the need for supervisors and injured employees to fill out and submit claim forms.

Within minutes of a call, the nurse sends an injury report via e-mail or fax to all of the appropriate stakeholders, including the employer contacts (the HR liaison and/or RTW coordinator), treating physician, and the claims adjuster. Immediate notification of injury enables stakeholders to initiate their respective roles in the process and to optimally affect the claim's outcome.

Because delays associated with lack of communication or stalled paperwork have been virtually eliminated, employers can achieve full compliance with on-time reporting (within 24 hours of the injury).

Cost-Effective Medical Care
Beyond timely reporting, another key challenge in workers' compensation is ensuring that every injury receives the care and treatment appropriate to its level of medical severity.

Although employers often train supervisors about how to appropriately respond to worksite injuries, these managers are not trained medical professionals and should not be expected to make treatment decisions. In the past, many worksite supervisors erred on the side of caution, sending injured employees (even those with minor injuries) to the emergency room, which could cost as much as $800 to $1,200 per visit.

As a result, organizations ended up using ER services in 20 to 30 percent of their claims, resulting in an unnecessary level of care and expense. The option of using a nurse call center can drastically reduce the number of unnecessary ER visits.

A nurse call center essentially prevents the supervisor from having to make treatment decisions, and instead the injured employee is able to speak directly with a medical professional. Using treatment protocols and sophisticated algorithms, the triage nurse systematically identifies the right course of treatment. In severe cases, a nurse will advise emergency care. With minor injuries, however, the nurse may provide simple first aid or self-care guidelines, or send the patient to an occupational clinic on the employer's preferred provider network.

After speaking with a nurse, many injured employees do not require or request additional medical services. In fact, 20 to 40 percent of all incoming calls result in “report only” or “first aid” injuries—cases that never enter the healthcare system.

Structured RTW Coordination
Central to a nurse call center's ability to support a structured RTW program is the establishment of an online database that houses an employer's detailed job descriptions and transitional work assignments for all essential positions in various departments.

Once an injury is reported, the triage nurse sends an injury report to the employer's designated RTW coordinator. Using the online database, the RTW coordinator can send a job description to the treating physician, who can use the information to make a more informed and accurate decision on whether to release the employee to full or modified duty.

If the injured employee cannot return to full duty, the RTW coordinator can quickly match the employee's work restrictions to an existing modified duty assignment. As a result, many employees are able to return to work immediately, reducing lost days and indemnity costs.

Improving Employee Satisfaction
In the past, an injured employee may not have received the level of treatment they required and the injury may have become worse. Without appropriate care or clear communication, injured employees may become dissatisfied and even disgruntled with their workers' compensation experience, and may even seek legal counsel to navigate what they consider a confusing and complex process.

Overall, attorneys are involved in five to 10 percent of all workers' compensation claims, and in roughly a third of serious-injury cases. Attorney involvement increases claim costs by as much as 12 to 15 percent; because claimants must pay attorney fees, there is generally no net gain in the actual benefits for the employee.

With a nurse call center, employers enable prompt and open communication with employees, starting from the day of injury. Injured employees appreciate the opportunity to speak with a nurse, who provides an objective medical assessment of their injuries and recommends an appropriate level of care and treatment.

Employers that provide this type of service send a clear message—that they care about their employees' health, safety, and well being. Due to these benefits, employees have a more positive workers' compensation experience; payers and employers have experienced as much as a 40- to 67-percent reduction in claims litigation.

The Future of Injury Triage
Ultimately, workers' compensation losses impact an organization's bottom line, so containing claims costs is key. A nurse call center provides the medical expertise and triage services to reduce claims by 20 to 30 percent. By initiating claims down a path of optimal injury management and quality medical care, organizations have reduced medical costs by as much as 20 percent, and by integrating a structured RTW program, injured employees recover and return to work sooner—reducing lost time by as much as 50 percent. All these benefits have enabled workers' compensation programs to decrease overall costs. These reductions have significantly helped employers, particularly in light of today's difficult economy and ever-increasing workers' compensation costs.