Workers CompensationCase Management

Iris Ayala

Occupational Health Manager

Kaolin Mushrooms

April 2011

Definition

Workers Compensation Case Management: • Refers to the planning and coordination planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation*

Achieves:o A reduction of barriers for employees o Improves the health care experience o Enhances the recovery periodo Reduces lost time and decreases time on modified duty

* Definition from Department of labor

Role of Case Manager• Assist employers decreasing WC and health care costs

• Coordinate injured workers’ return to work

• Keep employer and insurance company informed

• Provide required paperwork for insurance and employer

• Case managers act as: gatekeepers resource manager decision makers

• Serve as source of information for injured worker

• Monitor injured worker’s progress

• Broker and advocate

Importance of Case Manager To ensure a continuum of care until worker is released to full duty until worker is released to full duty

To act as a clinical advocate to ameliorate the problems associated with work related injuries prompt return to work

Impact of Injury Management• Economic Impact:

Indirect costs:o Loss of work dayso Replacement workerso Decreased productivityo Retrainingo Impact on other workers

Direct costs:o Medical costso Insurance

Early InterventionSteps to consider: Assist injured worker in obtaining prompt and appropriate medical care Complete and process proper paperwork Establish proper f/u treatment Ensure prescribed medications have been obtained and employee understands instructions Provide timely delivery of other benefits Begin the process of case management

Benefits of Early Intervention • Decreases barriers for obtaining medical care• Creates an opportunity to make immediate contact with injured worker• Able to obtain & preserve details of incident

• Can impact on compensability and/or offset opportunity

Creating Relationships• How well do you understand the responsibility of the WC carrier adjuster?• How well do you understand your states workers compensation laws?

• Do you know your numbers?• Do you know all of panel providers?• How well do your panel providers and claims adjusters understand your company’s scope of work?

Key Skills

• Meet with employee immediately or as soon as possible• Schedule prompt medical care• Ensure timely submission of paperwork• Accompany the employee to provider appointments

Key Skills continued…

• Ensure employee understands follow up as dictated by provider• Follow through on referrals testing, or PT ordered• Maintain in constant contact with employee• Link employee to needed resources• Document, document, documentDocument, document, document

Communication &

Return to Work

John Hillard, GSPRisk Manager and Safety Consultant

The Securus GroupA division of Murray Risk Management and Insurance

CommunicationWith the carrier:

1.) Don’t assume anything

- If something doesn’t seem right, question it!

- If you want to be included in the conversation, ask to be!

- Show the carrier that you are committed to improving losses, request a claim review!

CommunicationWith the agent:

1.) They/we work for you:

- If something doesn’t seem right, tell them/us to go to work for you!

- If you want to be included in the conversation, tell them/us to go to work for you!

- Show the carrier that you are committed to improving losses, tell them/us to go to work for you!

CommunicationTo-Do:

1.) Speak up when something doesn’t seem right

2.) If you want or need more communication, ask for it

3.) If you are having losses or having trouble communicating with the carrier ask for regular claim reviews

4.) If you are not getting action, tell your agent you are unhappy, they/we work on your behalf

Return to Work

Return to WorkBenefits:

1.) Positive Impact on WC premium

- Now a requirement for almost any WC carrier

- Positive impact on MOD factor

- Keeps the underwriters happy

Return to WorkBenefits (cont.):

2.) Reduced Claim Cost

- Studies show RTW to have a positive impact on shortening the claim

- Meaningful work can help prepare the worker to return to full capacity

- Prevents litigation by making the worker feel secure about their employment

Return to WorkBenefits (cont.):

3.) Reduces Fraud

- If they are working they aren’t watching daytime commercials

- Less inclined to ‘fake’ an injury if it is known that they will have to come back to work

Return to WorkMaking it work for you:

1.) It is one of the only tools you have, without it:

- You are asking to go to litigation without it

- You are asking to pay out to the worker

- You are looking to head to the state fund

Return to WorkMaking it work for you:

2.) Search for jobs before you have an injury

- Helpful when communicating with the MD

- Complete tasks that get ‘pushed to the bottom’

- Fail to prepare… prepare to fail

Return to WorkMaking it work for you:

3.) Flip the script

- Use injured workers to complete safety tasks

- Conduct safety training with the injured worker

- Have the injured worker to conduct safety audits

Return to WorkTo Do:

1.) Write a RTW policy NOW.2.) Translate and send to your workforce3.) List potential RTW positions4.) Following an accident remind your MD that RTW is

available for any restrictions.5.) Flip the script!

Questions?