As seasoned Worker’s Compensation professionals, and even for those of you who have just joined our little party, you are all aware of the crucial role you play in effectively managing claims, ensuring fairness to all parties concerned, and each of the identified stakeholders. It has been my experience, as someone who has run a cost containment concern for the Worker’s Compensation ecosystem for more than three decades, those who master the use of the cost containment tools available to them do not just survive, they absolutely thrive in terms of establishing their level of professionalism, completing each of their assigned tasks, and closing out the claim file.
One of the key strategies that all members of our ecosystem must employ is the strategic utilization of all cost-containment tools and maximizing the efficacy of this intervention. To accomplish this, one must start with an understanding of all those tools that are available. Obtaining clarity of the compensable injury from a clinical perspective, with the application of evidence-based medicine principles, enables you to make informed decisions at the right time with the best possible outcome.
Start with Early Intervention
The “Golden Hours” of any workplace injury occur as quickly as possible after the identified event. Obtaining the applicable clinical information as soon as possible tends to be more accurate. If the noted injury is suspected to be particularly serious, have a nurse case manager intervene in this case as quickly as possible.
Obtaining all appropriate clinical information as soon as possible will contribute to the best possible outcome in the claim file experience. Those successful claim file handlers clearly understand the benefit of immediate engagement with the injured individual.
Therefore, combining the nurse case manager intervention with prompt medical assessment and conversation with the injured employee contributes to the best possible outcome. Those specific tools available include an Early Compensability Assessment or Peer Review. Understanding the extent of the compensable injury, to an evidence-based medicine determination level, will dramatically influence the outcome of the identified injury.
A question to ask yourself: “How can I apply early intervention in my current cases?” Taking a peek at your newer files could only benefit and reduce your file count.
Master the Art of Clinical Peer Review
Understand that clinical peer reviews, particularly those who rely upon the standards of evidence-based medicine, are potent weapons in terms of delivering all appropriate care to the injured individual, providing only the care that is necessary to address the sequelae of the compensable injury, and this precipitates as rapid a resolution to the injury sustained as clinically possible.
When using these tools, examine the issues to be addressed and modify the templated questions to reflect the particular clinical situation as you understand it. Not every question is applicable in every clinical situation. Therefore, to obtain the most efficacious report, have that review target the specific areas where you have a concern.
Remember, each of these identified cost-containment vehicles are a specific investment that frequently pays dividends many times more than their relative expense. An additional benefit is that when you communicate the findings identified in the peer review with the injured employee and explain the rationale behind the determinations, this lessens the friction or contention between the injured individual and the carrier. This reduced friction will mitigate future expenses.
And do not forget to communicate with the employer, as they may offer insight not readily apparent in the records/documents presented for review. This additional engagement and conversation should focus on any possible return-to-work programs, with a meaningful protocol that enables and maintains a significant reduction in claim costs.
Conclusion
- Effective cost-containment is not about cutting corners; it represents a professional, intelligent, and strategic claim management scenario that benefits all parties concerned.
- Maximizing these tools does require an understanding and implementation of proactive management strategies.
- With the appropriate implementation, each claim file handler will achieve superior outcomes and build their personal brand as a trusted professional in completing their individual responsibilities.
- Early active intervention and clinical assessment are paramount in claim file handling
- This early and comprehensive clinical intervention will serve to benefit all those tangentially involved in the identified claim.
