By: Derrick Amato,
Vice President, Workers’ Compensation Sales & Strategy, MultiPlan
Early intervention (EI) by definition has an expressed expectation that workers’ compensation cases be triaged as soon as possible for determination of the need for first aid, self treatment modalities, direction of care, case management and/or other special needs based on the complexity of the claim. Many employers and claim payers see great value in having a nurse serve as the first point of contact once an injury has occurred. In a prior professional life, such a nurse triage product was one of several clinical products I had executive ownership of, so I have firsthand knowledge of its value and return- on-investment potential.
This concept has been readily accepted by many employers, carriers and TPAs who likewise see the value in “front ended ” services designed to deploy the right resources at the earliest possible time. If we view EI as one end of the spectrum, at the other end reside cases that don’t receive the right level of attention (regardless of causation), or breach disability guidelines, and become chronic and costly. Just look at cases that today cause systematic pain or those that yield financial complexities in trying to achieve desirable Medicare Set-Aside outcomes. What lessons can be learned from these less-than-desirable outcomes? With opiates and narcotics being prescribed in all too many cases for protracted periods of time, this area alone is deserving of an EI approach.
While diagnosis is most often the predominant metric used for managing cases because it is usually readily identifiable and can progress with diagnostic testing, therapies and time, it’s important to have insight into those areas that have proven influence on recovery duration and return to work success. These include co-morbidities and psycho-social contributors. With today’s aging workforce, underlying medical conditions can drive the cost of a claim to a multiple of the same claim where these elements are not in play. For example, a Duke University Medical Center analysis found that obese workers filed twice the number of workers’ compensation claims, had seven times higher medical costs from those claims, and lost 13 times more workdays from work injury or work illness than did non-obese workers.
Equally, psycho-social influences are known to have a hampering effect on recovery and result in further delay in return to work. It’s an area of claims management that deserves to be given more attention. The first stage in contending with this “contributor” is knowing more about the employee’s personal dynamics. Use of a telephonic or field base case manager can vastly improve the attention to detail these two areas are given. I am a big proponent of task-based assignments using case management services to accomplish some of this fact finding and in turn to help establish a plan that addresses the employee’s diagnosis, contributing factors included. Armed with such useful knowledge the claims professional is much better equipped to move the WC chess pieces in the right direction and ideally avoid adding to the plethora of high cost cases the industry has to reckon with.
Recognition of these underlying contributors early on is crucial, and it requires an early intervention investment. Achieving positive claim outcomes is predicated in large part on the engagement of case specific mitigation strategies — the timelier the recognition of need, the faster the reaction and deployment of appropriate interventions and the better the outcome.
Using early intervention techniques doesn’t mean adopting a worst case scenario approach to managing all claims. However, it does require a desire to make decisions early on and engaging processes to rapidly identify barriers that may hinder recovery. An eyes-wide-open view of each claim sets the stage for reducing the impact the “unknown” might create.
For the cost of an IME or a day’s surveillance a thorough and thoughtful clinical intake assignment can be made to case management. Endorsing early intervention is easy. Investing in it, is the next step. Have you made, or will you make the investment?
About Derrick Amato
Derrick Amato currently serves as Vice President, Workers’ Compensation Sales and Strategy for MultiPlan, Inc., the nation’s oldest and largest independent PPO network. Amato previously served in a senior level role for the Accident Fund Insurance Company of America, one of the nation’s leading workers compensation insurers with more than $3 billion in assets. Prior to joining the Accident Fund, Amato served as Chief Operating Officer for Coventry Workers’ Compensation Services clinical management service operations. Amato has 32 years of claims related experience in both the workers compensation and managed care fields. Amato began his career with Aetna where he learned workers compensation claims and managed a workers’ compensation claims unit.
MultiPlan, Inc. is the industry’s most comprehensive provider of healthcare cost management solutions. The company provides a single gateway to a host of primary, complementary and out-of-network strategies for managing the financial risks associated with healthcare claims. Clients include large and mid-sized insurers, third party administrators, self-funded plans, HMOs and other entities that pay claims on behalf of health plans. MultiPlan is owned by BC Partners, a leading international private equity firm, and Silver Lake, the world’s largest private investor in technology.