Choices Solution Center

Improving Information Flow

Overview
In a Workers' Compensation Claim, several things including disability payments are "time sensitive". Claims personnel, employers and physicians rely on timely and accurate medical updates, return to work and authorizations to prevent any delay in treatment, disability payments and or planning for the injured worker's return or absence. Inaccurate information can delay treatment and thus recovery time which affects every entity of the claim.

Choices nurses provide these updates and ensure that all parties are on the same page at the same time. This prevents excess disability payments for the claims personnel, working with the employer to minimize the financial and productivity impact in the absence of their employee, making sure appropriate medical treatment is authorized when needed to expedite recovery and prevent delays.

The nurse is also able to acquire return to work information and medical information from the MD in written and oral form that is sometimes difficult for the claims personnel and employer to obtain. The nurse (Registered Nurse) is able to work with the physician from "one medical professional to another" type of courtesy and has the respect of the physician where the physician may be less responsive to the opinion of the claims examiner. Physicians generally respect the medical training that registered nurses have and their opinions are typically valued by the physician, whereas the claims personnel opinions are viewed as coming from someone who does not have the medical background or training.

Choices nurses enjoy a very high level of respect within the medical community because of our medical knowledge, communication and professionalism. This allows us to work with the physician on their level. This gives our nurses a definite edge to affecting the medical treatment and moving cases forward, even with the most difficult physicians. Any who have had experience with our staff know what to expect and many times they know we will be asking them to defend and substantiate their findings and recommendations.

Case Study Example #1
An injured worker fell off a two-story roof and was rushed to hospital in critical condition. In response to an urgent referral, a Choices nurse made an immediate hospital visit and obtained current information on the worker's medical status. She also met with the injured worker's family for introduction and to provide emotional support. She facilitated authorizations (throughout claim to present time) for medical interventions, in-patient and out-patient rehabilitation facilities as recovery progressed, to allow the injured worker to reach maximum potential for returning as a productive worker and citizen.

The claims examiner and employer risk manager were continually updated on medical status, prognoses, stages of recovery, re-assessments and adjustments of rehabilitation programs, and estimates for return to work to ensure the most updated communication were available. The frequent and open communication allowed the carrier and employer to make any necessary decisions regarding claim and employee status from a medically informed standpoint.

Case Study Example #2
An injured worker with rotator cuff repair who had multiple surgeries was assigned a Choices nurse. The injured worker was approaching her maximum allowed physical therapy visits (24 visits). A medical physician documented objective findings to substantiate additional need for physical therapy treatments. The Choices nurse was able to communicate immediately with claims personnel and obtain authorization for treatments - which avoided delayed recovery.

Case Study Example #3
A police officer who had an industrial injury (back injury) was in a motor vehicle accident the morning of a doctor's appointment. She was rear-ended by a vehicle that was going approximately 30 mph. About 3 1/2 months prior to this accident she had a spinal fusion as a result of the work-related injury. This accident prolonged her rehabilitation, increased her pain, caused muscle spasms, a delay in return to work, and the need for MRI studies to rule out displacement.

With a Choices nurse's persistence and dialog with the injured worker, additional information about the claim was uncovered -- what happened and when. At the next office visit the nurse confirmed the time and place with MD and discussed apportionment and obtained percentages for physical therapy and delayed recovery. In addition, she also had a history of a non-industrial injury that had affected her entire recovery and need for surgery. Apportionment was discussed for this prior to this accident as well.

Result: As result of nurse's intervention and communication with physician , a cost savings was achieved of 80% of the surgery costs and 50% of the physical therapy costs associated with the claim.

Case Study Example #4
A nurse received multiple routine requests for durable medical equipment (DME) and was asked by the claims examiner to send it through utilization review. The cost of the review would have exceeded the cost of the DME's request and the order was a reasonable medical prescription for said injury. The nurse was able to discuss orders with the UR nurse and communicate to the claims examiner that it was not necessary to send through UR, thus saving the carrier the cost of UR for multiple request.

Result: A cost savings to this claim (UR requests run about $95.00 a request) as well as all the claims that would be handled by that particular CE that had the same type of request; and, improved communication between the parties working the claim.

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

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