How to Effectively Imbed Nurse Case Management in WC Claims

by Karen Wolfe

Nurse case management (NCM) has a powerful impact on Workers’ Compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, however widespread evidence of nurse impact has not emerged and objective proof of value is still missing. Several factors account for this.

Inconsistent referrals

For one thing, NCM’s are usually considered an adjunct to the claims process, called upon in sticky situations. Too often referrals to nurses is a last resort rather than an integral and standardized part of claim management.[1] When claims adjusters have the sole responsibility to refer to NCM’s, it can be subjective, uneven, and therefore unmeasurable.

Besides receiving referrals for sundry issues at different points in the course of the claim, nurses have not clearly articulated their case management interventions. Claims adjusters sometimes misunderstand the nurses’ approach. However, consistent referrals and standardized procedures can bring about major change.


Consistent referrals
Referrals to NCM should be made based on specific medical conditions in claims such as comorbidity like diabetes or problematic injuries like low back strains that tend to morph into complexity and high cost. Specific risky situations found in in claims data should automatically trigger NCM notification.


A recent article published in Business Insurance, “Nurses a linchpin in reducing workers’ comp costs”, points out how Liberty Mutual has developed a tool that notifies claims adjusters of cases that would most benefit from a nurse’s involvement.[2] Decision burdens for claims adjusters are eliminated. Referrals to NCM are automatic based on specific high risk situations found in the claim. Inconsistency disappears and several benefits evolve from this approach.


Process standardization
An operational process can be dissected and categorized, thereby gaining better understanding of its components and relative importance. Review the data to determine which medical conditions in claims result in longer disability, lower rates of return to work, and, of course, higher costs. Select the conditions in claims that should activate an NCM referral.


An example is a mental health diagnosis appearing in the data well into the claim process. A mental health diagnosis appearing during the claim for a physical injury such as a low back strain is a strong indicator of trouble. The injured worker is not progressing toward recovery. However, the only way to know this diagnosis has occurred in a claim is to electronically monitor claims on a continuous basis.


Data monitoring
To identify problematic medical situations in claims and intervene early enough to impact outcome, the data should be monitored continually. Clearly, this is an electronic, not a human function. When the data in a claim matches a select indicator, an automatic notice is sent to the appropriate person.


Standardized procedures
Catching high risk conditions in claims is just the first step. NCM procedures must be established to guide responses to each situation triggered. Standardized procedures should describe what the NCM should evaluate and advise possible interventions. Such processes not only explain the NCM contribution, they assist in documentation and are the basis for defining value.


Measuring value
NCM has been under-appreciated in the industry because measuring apples to apples cost benefit has been impractical. When claims adjusters decide about referring to NCM’s and individual nurses create their own methodology, variables are endless and little is measurable.


In contrast to the subjective approach, specific conditions in claims found through continuous data monitoring can automatically trigger a referral to the NCM. In response, the nurse is guided by the standard procedures of the organization. When referrals are based on specific conditions in claims and response procedures are delineated, outcomes can be analyzed and objectively scored.


Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that link analytics to operations, thereby making them actionable. MedMetrics analyzes data continuously and sends alerts as appropriate. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

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[1] K. Wolfe. Early Intervention Drives Better Outcomes, But is Not Really Pursued http://medmetrics.blogspot.com/2014/10/early-intervention-drives-better.html

[2] B. Kenealy. Business Insurance. http://www.businessinsurance.com/article/20150610/NEWS08/150619977?tags=|92|329|304