A work related injury could be catastrophic. Its cost doesn’t have to be.
Today, more than ever, efficient and responsible management of work-related injuries is essential. Significant costs and lost time can accumulate quickly without coordinated oversight. In many cases, the needs and priorities of injured workers, providers, and insurance carriers may differ, making effective communication and coordination critical.
A Nurse Case Manager from Catalyst for Claims provides clinical expertise and timely oversight to support appropriate care and facilitate safe, efficient return-to-work planning. Our focus is always to balance quality medical treatment with effective claim management and cost containment for the stakeholders involved.
Catalyst for Claims practices proactive, goal-oriented case management across all claims. Our objective is to support timely resolution by facilitating communication among providers, identifying barriers to recovery, and promoting appropriate treatment progression when clinically indicated.
Our services include:
Supporting coordination of medical care and treatment planning
Assisting with timely return-to-work strategies when appropriate
Promoting clear communication among providers, employers, and carriers
Identifying and helping reduce unnecessary duplication of services
Assisting with vendor and provider coordination and referrals
Supporting clarification of medical documentation and terminology
Monitoring treatment progress and outcomes
Assisting with cost-effective care coordination and resource utilization
We remain focused on delivering professional, responsive case management that supports all parties involved in the claims process.
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.
Experience has shown that when injured workers do not have coordinated clinical guidance, recovery and return-to-work timelines can be prolonged. Similarly, when a case is not actively managed by a Nurse Case Manager, opportunities for efficient communication, care coordination, and cost-effective treatment planning may be missed.
A Nurse Case Manager from Catalyst for Claims provides structured clinical oversight in the field, supporting communication between providers, employers, and insurance carriers. This helps ensure that care is appropriately coordinated and that key clinical and administrative information is clearly conveyed throughout the life of the claim.
Catalyst for Claims is committed to supporting timely, appropriate medical care while assisting clients in managing claim-related costs through proactive, professional case management services.
We welcome the opportunity to be part of your claims management team and to support your adjusters in achieving effective, well-coordinated outcomes.