A work related injury could be catastrophic. Its cost doesn’t have to be.
Today, more than ever, money cannot be wasted. Thousands of dollars are spent on work related injuries and hundreds of lost hours are accumulated. Injured workers', attorneys', and doctors' agendas may be quite different than the insurance carrier. You need someone on your side. That someone is a Nurse Case Manager from Catalyst for Claims, Inc.
A Nurse Case Manager immediately understands the injury and can plan and implement a return to work strategy, which always focuses on ensuring the injured worker the best medical care while providing significant cost savings to the employer.
Catalyst for Claims, Inc. believes in and practices proactive and assertive case management performance on all claims. Files that would normally take months to finalize are closed rapidly. Physicians who stretch out treatment lengths are encouraged to move the progress along. Non-compliant claimants suddenly feel responsible and accountable for their treatments. Employers feel relieved that someone finally places their best interest first, without ever sacrificing or compromising the employee’s medical needs.
Our goals are straightforward and specific:
Negotiate prices aggressively with vendors
Reduce the chances of medical complications caused by the claimant's injury
Avoid duplication of services
Expedite return to work status
Foster claimant compliance with treatment
Clarify medical terminology
Provide insight into the claimant’s medical history
Avoid unnecessary expenses
Furnish provider and resource referral assistance
Monitor length and outcome of treatment
For a better understanding of the benefits of having a Nurse Case Manager (NCM) assist your insurance adjusters on claims, we have provided the following case histories:
1. Calvin P. fractured his leg while working at his construction job. He was hospitalized and required surgery to repair the fracture. Upon being discharged, the attending physician ordered a walker and a commode, referred the claimant for home health aids for five days a week, 6 hours per day, for 2 weeks duration, as well as home therapy, and ordered an ambulette to take him home. The insurance company was billed $220.00 for the walker, $110.00 for the commode, and $500.00 for the ambulette. The home health aids would have cost $900.00 and home therapy would have cost $1656.00. The adjuster authorized all of the above simply because she could not assess what was necessary and what was not appropriate. If a NCM were handling this file in conjunction with the adjuster, she would have visited the claimant in the hospital. The cost of the walker would have been negotiated down to $150.00 and the commode to $85.00. She would have found out that the claimant’s wife is at home all the time; so home health aids would not be necessary at all. She would have assessed his mobility and determined that he is a good candidate for outpatient therapy, at a cost of $1108.80, instead of home therapy. She would have been able to assess his transferring capabilities and determined that he only needed a taxi to take him home at a cost of $65.00. The cost savings would have been a total of $1978.00 just on the date of discharge alone.
2. The physician gives Calvin a prescription for therapy and tells him to follow up at the office in 6 weeks. Calvin doesn’t know where to go. The physician is too busy to locate a neighborhood facility for him and the adjuster is not familiar with Calvin’s state of residence. His leg is now stiffening from lack of therapy. He goes back to his physician in 6 weeks, sore and in pain, and no therapy has been obtained. This delays his recovery by almost 2 months. If the NCM worked this file, she would have obtained the prescription for therapy, recommended a few local facilities, faxed over the authorization, and ensured the claimant's attendance. The length of recovery time would have been shortened by two months, complications would have been avoided, and the claimant would have been much more comfortable.
3. Calvin’s physician requests an MRI of his knee ($902.00) on the first follow-up visit. It is authorized and performed. The physician also asks for the claimant to see a neurologist ($100.00) to make sure that no closed head injury occurred. If a NCM were working the file, she would have obtained the MRI report from the hospital ($0.00), or would have at least negotiated the cost of a new one ($500.00). She would have obtained the MRI report from the hospital, showing a negative finding, therefore making an appointment with a neurologist unnecessary. The cost savings would have been $1002.00.
4. Time passes and Calvin is slow to respond to treatment. The adjuster is patient and waits for recovery. She decides to schedule an independent medical exam (IME) to determine if the claimant’s recovery rate is appropriate. She forwards all the medicals to the IME vendor. However, the IME physician never receives these medicals. He therefore recommends more therapy and treatment, documents continued total disability, and never addresses any return to work issues. The IME turns out to be a waste of money and time for all concerned. If a NCM were handling this file in conjunction with the adjuster, she would have known the Medical Disability Guidelines for recovery and would have expedited an IME much sooner. She would have ensured that the examining physician would have obtained the medicals so he would know exactly how much treatment the claimant already received. He would have determined that the claimant only needed a home exercise program. She would have forwarded the claimant’s job analysis so that the examining physician would have been able to determine that the claimant can return to work in a modified duty position immediately upon the exam. The IME physician would have decreased the claimant's disability to partial, the employer would have had the worker return to work 2 months earlier, and the cost of 3 more weeks of therapy ($369.60) would have been avoided.
5. Mary S. has an IME scheduled for classification and scheduled loss of use. The IME physician reviews the medicals but fails to realize that 3 months prior to the work related injury the claimant had a skiing accident that injured her leg. This IME physician claims the employer is 100% responsible for the claimant’s disability. A NCM would make sure that the IME physician would know about the previous accident, and in turn the physician would reduce the employer’s payment responsibility. The cost savings would have been a reduced responsibility to pay only 40% of the claimant’s disability instead of 100%.
6. Cindy P. has been out of work for 6 weeks with an ankle sprain. When asked why she hadn’t returned to work she simply replied, “My physician didn’t tell me I should go back”. A NCM would have consulted with the physician and discussed the recovery timeframe. After 2 weeks, the NCM would have actively encouraged the physician and claimant towards return to work status. She would have obtained the return to work documentation 2 weeks earlier.
History has shown that if the claimant has no guidance, recovery time increases. If the file has no NCM, the employer and insurance company leaves themselves open to unnecessary medical and lost time expenses. Catalyst for Claims, Inc. should be your eyes and ears in the field. It is your decision to save money and you should inform your adjusters that money must be saved. You should insist that the injured worker obtains the best medical care. You should request that Catalyst for Claims, Inc. be on your side!