The Value of Case Management

Case Management programs are an important component of the overall claim management strategy. Telephonic Case Management is a valuable tool that when used early in the claim can yield significant reductions in medical and indemnity claim costs. Different studies conclude that that the earlier case management is involved in a claim, the sooner the claim can be resolved. Industry analysis shows “55% of injured workers who are referred to case management within three months of injury experience return-to-work rates within disability guidelines.”¹ A study of 42,000 claims performed by Helmsman, the TPA for Liberty Mutual found when a nurse was on a claim, the injured worker returned to work faster. According to the report, “medical care costs are estimated to account for two-thirds of workers’ comp claim costs within the next four years, driven by increased deductibles, limited choices, reduced reimbursements, and conditions such as obesity and diabetes. The rise in opioid prescriptions further complicates claim costs.”² How a claim is managed—from injury to close—impacts how quickly the employee returns to work. Nurse involvement contributes to a 15% faster claim closure.


Early Intervention

Early Intervention: TCM has the greatest impact when an indicator or combination of indicators are identified early in the claim life. Some of the variables that would indicate TCM assignment include:

Body Part; i.e., back, shoulder, knee, joints, multiple body parts, etc.
Narcotic prescribed at risk-level thresholds
Claimant’s lack of motivation to return to work
Bill payments received for co-morbid conditions
History of previous injuries or surgeries

Mid-Case Triggers

TCM assignment should be considered when other factors occur later in the claim. TCM intervention can help resolve return to work and medical issues that arise from a co-morbid condition or psychosocial status. Some considerations for Case Management

Treating with multiple physicians
RTW is not documented and benchmark approaching
Treatment outside of evidence-based treatment guidelines
Injury involves a major joint that limits movement and/or functional ability
Surgery indicated or requested
High dosage(s) of controlled medications prescribed – average RTW delay of 69 days
Early MRIs – lead to unnecessary and costly medical services
Employee obesity – 25% higher risk of a work injury

Case Management is not necessary on every claim:

An injured worker without co-morbid conditions and a good relationship with their employer is already on track to a good outcome. Adding a nurse in this scenario probably won’t make a big impact on the outcome and will just increase claim costs.