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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Tendon Transfers and Decreasing Caregiver Costs

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

PRICELESS Hand function is, by most, considered the most important ability leading to independence with activities of daily living.  Attendant care is by far considered a medical necessity because of the lack of hand function needed by a person to groom, dress, eat, toilet, drive, use a phone, use a computer, manage money, and the list does go on.  Tendon transfers have been an elective surgical intervention for dozens of years but are for some reason, a well kept secret for populations such as spinal cord injuries.  No one would hesitate to offer Chipper Jones of the Atlanta Braves a tendon transfer if he had an injury that would warrant it.  But take a 23 year old C5-6 tetraplegic, and you will find recommendations such as a power wheelchair, hoyer lift, attendant care, occupational therapy, orthotics, assistive devices and assistive technology that are all costly, and require maintenance and replacement.  You will rarely, if ever find a recommendation for tendon transfers. Three primary tendon transfers, which are deemed very useful to the C5-6 SCI population, have the potential to strengthen pinch, grip, and elbow extension. A “key” pinch procedure might offer the ability turn pages, hold a book, take money out of your wallet, use and ATM, catherize yourself, write with a pen or pencil, brush your teeth, feed yourself with utensil WITHOUT a u-cuff or other device. Improved grip strength might allow you to grasp a water bottle, a doorknob, hold a medicine bottle and even take the cap off! Elbow Extension gives you triceps strength and increases your “work space”.  A person could then prop sit, help themselves scoot and sit, propel a manual wheelchair, and reach outward and upward. A young lady’s story at the Shepherd Center caught my ear.  She had been injured at the C5 level for almost 15 years.  She had attendant care, family and friends, and a husband and 2 small children.  She went through all three procedures on both arms.  The procedures themselves are outpatient.  She returned to therapy 3 weeks later for 3 times per week for 8 weeks.  Now she has a lifetime of independence she did not have for 15 years that does not require maintenance or replacement.  She was able to discard all assistive device and adaptive equipment.  She was able to put on her make-up,  catheterize herself and shave her legs. The best part of all this… she made her kids a homemade macaroni and cheese for the first time!  She was able to grip the egg, crack it, stir it up, get a GALLON of milk out of the fridge, open the top, pour, put a pot of water on the stove, grate cheese and...

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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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Best Practice – Physician Peer Review, LNC Report, or Both?

Posted by on Feb 8, 2012 in Blog, Claims Tools, Litigation Tools, Workers Compensation

It may seem redundant, or not cost effective; to utilize both a Physician Peer Review and an LNC Report. However, they both have a unique perspective. And when you combine the two, the result affords you a more complete timeline of both the events that have happened, and what may still occur with the patient. The Physician Peer Review  i have bad credit and i need a loanconsiders all casestraditional loaning process A major standard in the industry, a Physician Peer Review, or medical review, of the case can give you a pinpointed, detailed reporting of what has happened to date. It provides intricate details about specific pieces associated with the medical event and how those pieces fit directly together. More myopic in construction, the medical review yields very precise answers and insight to a medical event and subsequent treatment strategies. Simply put, consider it a very accurate snapshot in time of the patient and the event. The LNC Report  Also a major standard in the industry, the LNC takes the medical review and expands it. It provides information about peripheral factors relevant to the case as well. It considers long-term patient care and interaction, the insurance role in the completion of the case, and a review of all record keeping involved. This broader approach can easily yield inconsistencies that may otherwise go undetected. It can also yield administrative concerns that can directly affect other cases. Using a Whole Person Approach The patient involved may have a single event or episode in your facility. But the effects and ramifications of that single event can weigh heavily on the future treatment of all patients. By utilizing both reports you garner a more complete picture of the patient’s impact on the health care profession and the associated support industries. Without using both reports, you could very well end up making future patient decisions with one eye closed. Crossexamine: Do you utilize LNC reports and Physician Peer Reviews as litigation tools?  Image credit: shutterstock dot...

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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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5 Critical Aspects for Successful CAT Case Management

Posted by on Dec 14, 2011 in Blog, Case Management, Nursing, Workers Compensation

Acknowledging that each individual case is different within its specific merits, some critical commonalities exist regarding the successful management of any catastrophic case. These commonalities include the perspective of healthcare providers and their associated facilities, as well as the perspectives of the individual patient and his or her family. A catastrophic Nurse Case Manager is a key player in helping to successfully manage a catastrophic injured patient/worker. Costs  Cost represents the pinnacle concern and the top influencing factor in patient care — not just the costs incurred by the health care organization, the associated health care professionals and administrative staff, but also the costs for the patient as well (unless the injury is work related). While patients are obviously thankful for receiving quality healthcare, the doctors, nurses, staff members and other providers — and even any equipment present — all look like dollar signs when viewed through the eyes of the attorney, insurance adjustor, and patient, or their family. It is easier for the health care provider to see and understand the needed costs and long-term benefits of care. Patients, their advocates, and non-medical participants find seeing these benefits more difficult. Providers must manage costs carefully, keeping in mind the importance of the cost-benefit relationship. Communication  By communicating these benefits effectively with the patient and his or her advocates, the physician increases patient compliance with the long-term recommendations. This transparency also builds confidence among insurance adjustors, attorneys, and other patient advocates regarding the quality and appropriateness of the provided healthcare strategy. WWW.CIARAGERAGHTY.COM/WP-CONTENT/UPLOADS/2011/09/1/payday cash todaynon broker payday loans This communication must bear a tone and quality that the patient, and his or her advocates, can readily understand. Providers that lack proper bedside manner, or the ability to convey the relevance and appropriateness of care, almost guarantee that the patient and patient advocates will balk at the recommended long-term care strategy. This is especially true when high dollar strategies are requested for extended periods of time or for chronic problems/conditions. For successful management of the catastrophic case, the patient and all involved advocates must have full disclosure regarding all aspects of the case involving their health, treatment plans and recovery — from start to finish. Availability and Caring Patients and their representatives greatly benefit by participating in transparent communication between the attending staff and other caregivers. Transparent communication refers to the availability of staff to competently answer questions and address concerns in a suitable, satisfactory way and in a timely manner. This transparency and availability of staff to offer support that proves transparency of care, quells many fears, foments compliance, and creates an environment of caring. Patients know that they are being cared for, but do they know that anyone cares?...

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