By Mariellen Blue, RN, CCM, National Director of Case Management, Genex Services
It’s no secret comorbidity factors have taken a toll on workers’ compensation. In the past decade, the percentage of workers’ comp claims with a comorbid diagnosis (diabetes, hypertension, depression and obesity) has nearly tripled, according to the National Council on Compensation Insurance (NCCI). The situation is even worse when it comes to addiction, with drug abuse in workers’ comp quadrupling during that time.
While case severity tools like ODG Comorbidity Calculator factor in comorbidities to help workers’ compensation professionals predict disability duration and cost based on the total claim picture, these factors aren’t always evident in initial diagnosis.
Practitioners who don’t dig deep to uncover and factor comorbidities into their assessment, particularly in workers’ compensation, are doing a disservice to the injured worker and claims administrator. For instance, NCCI found that 81 percent of cases involving an obese injured worker resulted in indemnity payments. More needs to be done to look beyond the compensable diagnosis which really doesn’t tell the whole story.
Consider the case of a 30-year-old male, who presents with an initial diagnosis of lumbar sprain and strain. A professional benchmarking this particular case using only the compensable diagnosis may rate it as a relatively low risk injury on the scale, with an estimated return-to-work date in the range of 14 to 19 days.
However, what if this individual is a smoker? If his BMI score is 30 or higher? If he’s coping with psychosocial issues and has been prescribed opioids longer than 30 days? When we factor in these comorbidities, we see a much more complex picture with a case severity score that has doubled from the initial diagnosis, placing the injured worker in the high-risk area. This suddenly becomes a case that is likely to result in a poor outcome if left unmanaged.
But, if these comorbidity factors are determined and addressed, a more accurate case severity score can be obtained soon after diagnosis, allowing the health care professionals to develop a more accurate protocol for the patient and help the adjuster plan for a more realistic timetable for return to work.
Case Management Intervention
And this is where case management can really make a difference. These professionals, whether telephonic or field, are skilled at conducting initial case assessments with the goal to achieve a complete history, whether a condition is related or unrelated to that compensable injury.
In addition, case managers often consult clinical protocols including ODG, MD and ACOEM guidelines. Because of their frequent contact with injured workers, these professional act as advocates, building and maintaining trusting relationship, which can often reveal insight into an injured worker’s situation that help determine treatment recommendations. If an injured worker exhibits signs of depression or deterioration, or has multiple comorbidities which may inhibit improvement, the case manager has first-hand insight to identify these triggers.
Because they’re in constant communications with all providers in a claim, case managers can also consult with these health care professionals to determine new care plan strategies and uncover resources to help the injured worker get the care he needs.
As workers’ comp experts, case managers can run into problems when injured workers, physicians or providers are unfamiliar with their state’s rules and regulations or the most effective return-to-work guidelines. This can cause the patient to guide the protocol rather than the health care professional.
Individuals who are experiencing overriding issues that aren’t addressed are less likely to be compliant with their healthcare treatment plan or, sometimes, even understand what that healthcare treatment plan is. Best workers’ comp practices empower case managers to view that injured worker in terms of the whole person and not just isolated to that compensable injury. The earlier this occurs in the claim process, the more likely the injured worker will receive a severity score that reflects his condition.
About Mariellen Blue
Mariellen Blue is national director of case management at Genex Services where she is responsible for overall product management and development, as well as quality assurance initiatives related to utilization management, telephonic and field case management, IME, and MCO services. A graduate of the Helene Fuld School of Nursing, New York, Ms. Blue has an extensive background in nursing, case management and utilization review.
About Genex Services
Genex Services is the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines. Genex is a managed care leader with more than 2,900 employees and 47 service locations throughout North America. The company serves 381 of the Fortune 500 companies as well as the top workers’ compensation and disability carriers and third-party administrators in the U.S. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
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This is not a paid placement.