Workers Compensation Case Management Iris Ayala Occupational Health
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Workers Compensation Case Management Iris Ayala Occupational Health Manager Kaolin Mushrooms April 2011
Definition Workers Compensation Case Management: Refers to the planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation* • Achieves: A reduction of barriers for employees o Improves the health care experience o Enhances the recovery period o Reduces lost time and decreases time on modified duty o * 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 § 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: Direct costs: Indirect costs: Medical costs o Insurance o o Loss of work days o Replacement workers o Decreased productivity o Retraining o Impact on other workers
Early Intervention Steps to consider: v Assist injured worker in obtaining prompt and appropriate medical care v Complete and process proper paperwork v Establish proper f/u treatment v Ensure prescribed medications have been obtained and employee understands instructions v Provide timely delivery of other benefits v 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 or as soon as possible immediately • 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
Communication & Return to Work John Hillard, GSP Risk Manager and Safety Consultant The Securus Group A division of Murray Risk Management and Insurance
Communication With 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!
Communication With 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!
Communication To-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 Work Benefits: 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 Work Benefits (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 Work Benefits (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 Work Making 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 Work Making 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 Work Making 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 Work To Do: 1. ) Write a RTW policy NOW. 2. ) Translate and send to your workforce 3. ) List potential RTW positions 4. ) Following an accident remind your MD that RTW is available for any restrictions. 5. ) Flip the script!
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