Choices Solution Center

Addressing Non-Work Related Conditions

Overview
Frequently questions arise regarding industrial injuries (work-related) versus non industrial (non-work related injuries or disease processes); in other words, when an injured worker sustains an injury, but already has a pre-existing condition.

How do you make sure that the MD treating for the industrial condition is only addressing/prescribing treatment for the work related injury and not adding work-related and non-work related injuries together?

Case Study Example #1
An injured worker reports falling down and bumping his head. He is treated for 7-8 months under workers' compensation. Because of the length of time the case is open, a Choices nurse is put on the case. During initial assessment, interview and review of medical records, the nurse suspects that the injured worker has Parkinson's disease. Further research uncovers this diagnosis and the reason for his fall was due to medications being taken for Parkinson's. The injury was not due to work. Case was referred to group health and closed to case management. The nurse's experience, attention to detail and skill set allowed her to identify a non-industrial condition and redirect the medical care to the right venue (group health).

Result: Savings on claim costs, employer costs, medical costs, identifying non-work related injury, re-direction to group health venue, resolved languishing case.

Case Study Example #2
An injured worker files claim for an aneurysm due to four-year accumulation of inhalation of chemicals at work. A Choices nurse is assigned to the case and upon review, a correlation is made between diagnosis and reported mechanism with no medical research to substantiate the claim. The nurse educates the claims personnel and employer on causes of aneurysm in direct correlation to reported mechanism, advises claims personnel and employer to obtain a medical opinion through utilization review, requesting the physician to address medical probability in direct relation to the diagnosis. Case closed and redirected through group health - injury not work related.

Result: Reducing claim costs (Saving of $10,000 to employer and carrier for identification of non industrial condition as employer is required by law to authorize up to the first $10,000.00 of medical treatment; savings on potential medical and surgical treatment; savings to carrier on disability benefits for lost time from work; savings to employer on temporary personnel to staff employee's position.)

Case Study Example #3
An injured worker who was previously discharged from care, returns for treatment for flare-up condition. A Choices nurse is requested to go out on a task assignment only to attend a physician appointment with the injured worker and the MD. The nurse discussed current symptoms and industrial injury symptoms with the MD, who determined that the symptoms were related to diabetes and not to her previous work injury. Care redirected to group health.

Result: Choices Nurse reduced claim costs and medical treatment which was re-directed to group health carrier under appropriate venue. Nurse intervention saved on the cost of second opinion consult, treatment, and temporary disability payments by intervention with medical physician regarding the injured worker's current signs and symptoms.

Case Study Example #4
An injured worker sustains an injury to her back and is off work for an extended amount of time. The injured worker is also pregnant. A Choices nurse is assigned the case and meets with physician. The MD is asked "absent the pregnancy, would the back sprain have resolved at this time?" The physician stated "yes" and deemed that the injured worker had recovered from the work-related injury and was permanent and stationary.

Result: Reduced claim costs via reduced temporary disability; care re-directed to group health carrier; disability benefits shifted to appropriate disability carrier out of the workers' compensation arena.

Case Study Example #5
A claims examiner who had a languishing (long open) case was not able to close it due to a treating physician not providing a permanent and stationary (P&S) report. A Choices nurse was ask to do a "task assignment" (a one time request) to meet with the physician and obtain the P&S report. The nurse met with the MD who promised the P&S report in one week. The nurse returned to acquire the report at the promised time and the MD did not have report done - citing an excuse that her typist had quit and she had a pile of reports that needed typed. The nurse volunteered to type report while the MD dictated. The nurse left the office with P&S report in hand and signed that same day, and hand delivered to the carrier (claims examiner).

Result: The case was closed in less time.

Services we provide to TPAs, insurers and other claims professionals include:

  • Workers’ Compensation Case Reviews
  • Field & Telephonic Case Management
  • Catastrophic Case Management
  • Utilization Review
  • Task / Limited Assignments
  • Early Return-to-Work Assessments & Programs
  • Early Intervention Programs
  • Ergonomic Evaluations & Prevention
  • Job Descriptions & Analysis
  • In Service Training for Employers, Physicians and Treatment Teams
  • CEU Program for Nursing Staff

6 Signs It’s Time
When is the right time to consider bringing in a nurse case manager? What difference can a nurse really make in speeding case closure?


more

Food For Thought
Ask about Lunch & Learn seminars and training workshops in your office! Current topics presented at no cost by our subject matter experts. CEUs available.

more

Case Closed Solutions Blog
The answer you’re seeking might be here! Find concise solutions to real-world challenges faced by claims professionals and employers.

more