‘FIRST CALL’ system saves workers comp dollars
Nurse case managers get workers back on the job faster

By Karen L. Andalman McIntyre

Workers compensation-it’s a term that alarms many employers. And it’s no wonder. Consider these statistics:

On an average day in the United States, 17,000 workers are injured, with work-related injuries costing the economy more than $110 billion a year.

A total of 5.2 million injuries and illnesses were reported in private industry workplaces during 2001, resulting in a rate of 5.7 cases per 100 equivalent full-time workers, according to a survey by the Bureau of Labor Statistics. Of the 5.2 million total injuries and illnesses, roughly 2.6 million required recuperation away from work or restricted duties.

Average workers compensation insurance premiums and other costs run 2% to 3% of payroll, and in extreme cases they can equal as much as 80% of payroll.
While these statistics may be alarming, taking control of your workers compensation program can cut annual direct costs by 25% to 50%. The most effective way to take control of your program is to implement a “first call” claims management reporting system, which directs employees to appropriate care at the start of the claim. A first-call system:

• Promotes communication among all parties involved.
This is really the key to a successful program. A first-call system promotes communication among all parties: the injured employee, the employer, the provider of the medical services and the nurse case manager. As soon as the injured employee makes this first call to the nurse case manager, the case manager becomes the hub of the three-point contact, coordinating services and communication.

• Directs the injured worker to the appropriate provider of services.
From the initial call, the nurse case manager directs the injured employee to quality providers and often negotiates discounts for services. This avoids situations where a patient first sees an internist or general practitioner, instead directing him or her to the proper specialist from the start.
Expediting expert treatment cuts costs by making sure the injury isn’t worsened
and by eliminating unnecessary doctor visits.

• Gives the injured worker a nurse advocate.
The assigned nurse case manager works one-on-one with the injured employee throughout the case-from first call through return to work-to make sure he or she is getting the best care possible. Throughout the case, the case manager continually follows-up with the injured employee to make sure he or she is following the treatment plan, observing physician orders, taking prescribed medications and going to physical therapy, if ordered. The nurse case manager can also interpret the physician’s orders to the patient.

• Assures parties involved that the process is positive.
Because there is a nurse advocate assigned to the case, adversarial relationships among the employer, injured employee and physicians do not arise. The employer is assured that the employee is doing everything to take care of the injury and return to work as soon as possible. The employee feels that the employer cares and that he or she is receiving appropriate care. And physicians get a timely response for approval to render services.

• Guarantees a quicker return to work, thus saving money on disability payments.
We have found that a first-call program closes cases 50% to 75% sooner. A nurse advocate, with his or her ongoing positive relationship with the employer, continually works on creative back-to-work or light-duty alternatives for the injured worker. Employers are usually more amenable to partial or light duty when they are assured by the nurse case manager that the patient is complying with treatment orders.

• Promotes successful outcomes and limits costly litigation down the road.
The ability to sue an employer varies on a state-by-state basis. In general, there are three reasons injured employees sue their employers: they feel they are not being treated fairly; they feel they are not getting appropriate medical treatment; or they are not receiving their disability payments.

However, if a patient thinks the employer is providing appropriate quality medical care, the case is less likely to go into litigation. Most employees do want to get better and return to work.
Here’s how the first-call program works. When the employee is injured, either the employee or the employer places a call to the company’s first-call number. The case manager, who is always a registered nurse, obtains the demographics and details of the injury, makes a medical assessment and then refers the injured worker to the most appropriate network provider.
It is during this first call that the registered nurse initiates the management of the claim and early intervention.

Working with the medical provider, the nurse case manager obtains and certifies an acceptable treatment plan, outlining specifically the medical outcome expectations, practice protocols and utilization criteria. The nurse case manager then notifies the claims payer of the treatment plan. All referrals to specialists or hospitals-as well as second opinions, home health care and rehabilitation-are coordinated and approved by the first-call registered nurse. This case manager manages the claim for its duration, making sure the injured employee adheres to the treatment plan, that proper medical protocols are followed and that medical improvement is reviewed regularly.

A well-designed and properly monitored first-call management program will undoubtedly produce cost savings for employers. Aggressive claims management, coupled with well-designed loss control programs, go hand in hand with controlling costs.

Karen L. Andalman McIntyre is president of Managed Care Concepts, Inc., a Chicago-based provider of utilization review, medical large case management and workers compensation claims management programs