Keeping workers compensation costs under control, Part 1

Posted by on Jun 12, 2014 in Blog, Case Management, Claims Tools, Legal Nurse Consulting

Strategies when English-as-a-Second-Language creates obstacles By Joyce Salyers, BSN, RN, LNC, CCM No hablo Ingles. не говорю по-английски. 난 영어 못해요. No matter what the language, “I don’t speak English” probably translates into higher costs and more time necessary to resolve your workers compensation claims. Awareness of these factors and savvy strategies to manage them will help you contain your costs.  Here are a couple of issues involving your non-English speaking IW and ways to translate them into a successful RTW: Interpretation.  Communication between the IW and the medical providers is key to a successful RTW.  But this process slows and falters when the IW is not fluent in English.Solutions?  The use of a certified medical interpreter at all medical appointments can help relay subjective information from the IW to the provider and ensure adequate understanding of all care instructions from the provider to the IW.  Working with an interpreter slows an appointment and requires patience because everything must be said twice, but there is no shortcutting this process to ensure adequate understanding in the medical information exchange. Transportation and Housing.  Non-English speaking workers are often in the US as part of a seasonal work crew with no access to independent individual transportation.  Their employer might provide transportation to medical appointments, but if the crew moves on to another location, then medical transportation must be arranged for appointments, picking up prescriptions and the like.  The same is true for housing.  The IW may lose the assistance and companionship of fellow workers who relocate to follow the work while they stay behind to receive medical care.  Buttoning a shirt or preparing a meal isn’t so simple with a broken arm and no one around to help.Solutions?  A reliable medical transportation company, ideally with a bilingual dispatcher, will ease transportation challenges.  Sitter or home health aide services may be necessary for basic assistance with ADLs when the IW has no local family or friends.  Housing the IW close to the medical providers keeps transportation costs in check.  The use of community resources such as churches and same language social groups help to fill in the gap of emotional support when the IW is far from home. A language barrier need not be a barrier to successful and timely resolution of your claim.  With attention to a few details, you will know that a prompt “Return to work, without restrictions” is possible to hear…in any language. Joyce Salyers, BSN, RN, LNC, CCM, is a Legal Nurse Consultant with MKC Medical Management.  Contact Joyce at and...

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Batteries Not Included

Posted by on Feb 11, 2013 in Blog, Case Management, Case Management, WC, Workers Compensation

Batteries Not Included A case management perspective: A catastrophic claim can cost millions.  We have a team of professional, clinicians, diagnostics and an arsenal of resources to manage a cost-effective outcome.  What happens when the injured worker comes without coping skills, a pre-morbid history you do not have access to, and an aversion to intervention? How do you identify that a variance or sentinel event may be genetically pre-determined creating an indirect causally related condition that requires savvy case management. no fax payday loans fast Mr. “Smith” is a 29 year old shot on the job.  He sustains a SCI resulting in paraplegia.  The history you have available to you says he lived alone, independent, military background, attending college, with family support.  He flies through inpatient rehab ahead of schedule and is preparing for discharge to the community.  Without warning, he becomes despondent, suicidal, and is unsafe for discharge.  Counseling is called in and determines he has major depressive disorder.  The injured worker is discharged with 24 hr attendant care and an antidepressant.  He and you have left the confines of an interdisciplinary environment. As a case manager you must use critical thinking skills to put a new interdisciplinary team in place, and fast.  Mr. Smith needs medication management from a psychiatrist to start. He should continue with counseling.  Close communication is required from all parties including attendant care to monitor and assess the situation.  The treating physician must be aware of treatment plan and support the expectation for improvement.  Mr. Smith’s “new” baseline is not a cost-effective solution to his long term needs, but some may be tempted to think his needs are being met. Mr. Smith responds to medication and is no longer suicidal however, develops secondary and avoidable complications such as a UTI and skin issue. A good case manager would start to suspect depressive disorder is not the only thing going on.  Collaboration with post-acute interdisciplinary team reveals behaviors that are self-defeating. Poor communication from the injured worker seems avoidant in nature.  A neuropsychological exam can help identify severity of adjustment disorder and possible underlying AXIS IV diagnosis.  In Mr. Smith’s case, an underlying personality disorder has been exacerbated.  The case manager must now add behavior management to coordination of care.  Behavior?! How can behavior management be the responsibility of Worker’s Compensation?  How can it not! In this case, the risks of life-threatening secondary complications proved to be the result of “batteries not included”.  Mr. Smith needs what I like to call an “accountability plan”.  His inability to want to get out of bed, attend outings and appointments, eat, catheterize himself properly, and check his skin now becomes a shared responsibility.  Orders are requested from...

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Provider And Claimant Insurance Fraud

Posted by on Apr 24, 2012 in Blog, Case Management, Workers Compensation

Insurance fraud has existed ever since insurance has been available as a commercial enterprise. Fraudulent claims account for a significant portion of all claims received by insurers, and cost billions of dollars annually. There are many types insurance fraud and occur in all areas of insurance. Insurance fraud occurs when any act is committed with the intent to fraudulently obtain some benefit or advantage to which they are not otherwise entitled (whether this is a claimant or a provider) or an insurance company knowingly denies some benefit that is due and to which someone is entitled. Insurance fraud crimes range in severity, from slightly exaggerating claims to deliberately causing accidents or damage. Fraud also affects the lives of innocent people, both directly through accidental or purposeful injury or damage, and indirectly as these crimes cause insurance premiums to be higher. These crimes pose a very significant problem, and governments and other organizations are making efforts to deter such activities. The conservative annual estimate of health care fraud in the U.S. is $80 billion, with some estimates twice that amount. In fiscal 2011, $4.1 billion in fraudulent claims was recovered by authorities, according to the departments of Justice and Health and Human Services (HHS). Still, officials say, the battle against health care fraud is never ending. Let’s begin by covering possible Health Care provider fraud behaviors.         Possible Health Care Provider Fraud Behaviors Spotting The Red Flags! Below are some behaviors that can indicate fraudulent activity by a health care provider: Providers who… Bill for treatment on consecutive dates of service for minor injuries. Work with the same attorney(s) that repeatedly have similar questionable claims. Bill for services that did not occur. Bill for services that were not received. Bill for unnecessary medical equipment. Pay an agent or other person for referrals. Charge workers for medical treatment on their claims. Provider offices where you observe… Increased injury claims after a business closure. Claimants move away but bills are still being sent on their behalf. High volumes of prescription drugs not appropriate to the injury. Claimants using prescription drugs for uses other than intended (selling, trading for street drugs, or as payment for services). Interpreters acting as advocates on the claim, steering the injured worker to different clinics, physical therapists, etc. Now let’s look at some possible claimant fraud behaviors. Possible Claimant Fraud Behaviors Spotting The Red Flags! Below are some behaviors that can indicate fraudulent activity by a claimant: Multiple claims. No witnesses. Failure to report an injury in a timely or immediate manner. Intentional misrepresentation of facts. Claimants who are not ambitious about getting back to work. Different symptoms for different providers/Moving or changing symptoms of pain....

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Hiring an NCM – Why Early On Is Better Than Later

Posted by on Jan 18, 2012 in Blog, Case Management, Workers Compensation

Imagine this scenario.  You are assigned case that involves an OJI (on-the-job injury).  You set up a time to meet with this injured worker, but he stands you up.  You make several phone calls and leave a number of messages hoping he’ll call you back.  When he finally returns your call after several weeks, he is irascible, belligerent and altogether uncooperative.  You try to gather as much information to corroborate what you have gleaned from his medical records, but you’re getting nowhere. Does this sound familiar? There is, of course, a simpler and far more effective solution to the above scenario.  Enter the Nurse Case Manager or NCM. The nurse case manager moves within the circle of medical care of the injured worker (IW), employer and employer insurance company.   She helps develop a care plan suited to the patient; balancing the clinical, functional, vocational and often emotional aspects as part of a holistic approach to the workers compensation (WC) driven medical care. Reasons to Hire an NCM There are several reasons why a NCM is critical to a WC case.  And it should not matter if you are an adjuster, defense attorney or plaintiff attorney; EARLY involvement of a nurse case manager in a worker’s comp case and (if done properly by the NCM) can prove highly beneficial. Because the NCM is responsible for presenting the patient’s case and/or medical and vocational issues without bias, you can trust her professionalism and expertise, making it easier to gather information. By hiring an NCM early on, you can rest assured she will monitor the patient’s treatment plan and recovery over time. Nurse case managers spend considerable time with the patient/IW to properly assess their condition.  They delve into the details of their lifestyle and develop a plan to help them get back on their feet, and hopefully back to work. When a NCM is brought on the case, she will analyze and assist with job/work environment issues while assisting with the other aspects of the case. In turn, this will reduce the costs incurred by the insurance company and ensure the patient is ready and able to return to work safely. Injured workers and patients see nurse case managers as caring and compassionate and are more likely to trust them and follow their advice.  Hiring an NCM early on will give the patient/IW an opportunity to build a relationship with them thereby benefitting the patient, employer and the insurance company in the long run. It’s never a mistake to hire a nurse case manager early on – only mistakes in which nurse case manager you...

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Another Important Must-Win Case? Get The Edge You Need to Win

Posted by on Nov 30, 2011 in Blog, Case Management, Legal Nurse Consultant, Litigation Tools, LNC

Thanks to television courtroom dramas and the 24-hour live news cycle, we’re all familiar with expert witnesses.  Perhaps none are more dramatic than medical experts who, when they take the stand, can make or break a case.  Though these moments make for exciting TV, in actuality, no one from either side of the room relishes landing in court.  While doctors are certainly well versed in their field of medical practice, few have much practical experience in the field of law.  When you add a Legal Nurse Consultant (LNC) to your legal team, you gain an invaluable asset with specialized insights in both arenas — and, LNCs do most of their work behind the scenes—where it really counts. TOP Reasons To Add a Certified LNC To Your Legal Team  Time is Money—Save Both An LNC is both cost- and time-effective.  Whether the LNC conducts a pre-trial screening of complex medical records, or reviews medication and therapeutic treatment protocols, her dual knowledge of medical and legal procedures provides that intangible edge for your team – an edge that could mean the difference between winning and losing. LNCs act as “medical interpreters” to both distill and translate the technical issues that are critical to all phases of your case— arbitration, deposition, mediation, validating case merits, fraud detection, pre-trial preparation.  This leaves your staff free to focus on the core legal tasks and prep. Merits of the Case—Build a Solid Case  No matter how many times those outside the legal field see contracts and other legally binding instruments, it’s always prudent and recommended that an attorney review the documents before any signatures find their way to the page. Likewise, even though you may have a strong knowledge of medical terminology, treatment strategies, and medication protocols due to your prior litigation experience, there’s still a significant chance you may miss something critical to the case buried in (or missing from) the medical records. You don’t want to pay the high fees commanded by medical doctors to review the medical aspects of your case file – save your physician expert, and the fees associated with his services, for in-person testimony before the judge at trial, for expert deposition OR for a laser pointed desk review/consultation. A certified LNC can handle all aspects of case review and claim/file validation behind-the-scenes. A qualified LNC possesses a deep working knowledge of medical and associated case terminology as well as causality, case merit, and expert witness selection expertise. Bring an LNC in to review the merits of a case before using scarce and costly resources before case merit is unequivocally established.  In addition, the LNC report/work product is very different and should give a broader view of the case,...

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Knowing Your Provider

Posted by on May 12, 2011 in AALNC, Blog, Case Management, Legal Nurse Consultant, LNC, WC, Workers Compensation

As a LNC/NCM I am often asked to help identify physicians to assist/work on a file/case OR help navigate the provider-client-payor waters. This is especially true in the Workers Compensation arena. Most recently this topic was discussed at length in a LinkedIn discussion group. Several excellent points were made. Noted in the discussion group: Does a provider have experience in your desired service? Be aware of reimbursement issues. Learn the State Rules and Regulations concerning WC. Check out the State website for details and reporting guidelines. Check out guidelines such as ODG, or MD Guidelines to verify that the client is tracking along with their recovery or rehab. ACOEM (American College of Occupational and Environmental Medicine) provides a guide to help assess outcomes. Some of the more basic ones that I utilize are: bad credit instant approval loanspayday loan online direct lender no credit check Check with other adjusters and attorneys for their experiences with the provider. Local NCM/LNC are very knowledgeable about the physicians in the area and can give solid insight as they often deal with the providers on a first hand basis. An employers will also know which doctors are easy to work with, take a certain type of case, etc. especially providers that will provide front line care such as family practice, occupational medicine, etc. If possible ALWAYS pre-screen the physicians. Learn how they report, communicate, how they interact with a NCM/attorney/insurance company, etc. Try and learn the “particulars” of the office staff. Periodically re-assess the physician and support staff. People change within a practice; physicians get busier and become unable to communicate as well; practice philosophies, and goals change. Seek feedback from the employers as to how their provider choices are or are not performing. Ongoing assessment of the physician(s) should be done. Help to educate the payor, employer, and provider on what to expect in regards to reporting, State regulations, employer RTW philosophies, etc. Does a physician embrace modify duty? We sometimes forget that the medical arena is consumer based. Knowing how your provider is performing is critical to successful...

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