By Vonesa Wenzel, Partner, HomeCare Connect
According to a recent NCCI presentation, more than 15.3 percent of the medical dollars in $1 million-plus workers’ compensation claims is spent on home health services. To put that in perspective, the prescription drug spend on these claims was 15.6 percent and inpatient hospital cost was 27 percent.
These complex home health cases usually involve injuries to the central nervous system or multiple body parts. They require high levels of nursing, durable medical equipment (DME) and often home modifications. In addition, some injuries result in amputations, requiring prosthetic devices.
Clinically driven managed care is the path to obtaining true savings while delivering the highest level of care. That means harnessing technology and clinical expertise to reduce lag time in:
- Initial referrals
- Care delivery
- Home modifications
Clinically driven care focuses on selecting and delivering services and equipment that will deliver the best outcomes in the shortest amount of time. It starts with a speedy referral process, ideally handled by someone with a clinical background who can clearly communicate with physicians’ offices and discharge planners. Having 24/7, live-person coverage of referrals along with weekend staffing ensures that DME and nursing services are in place when the injured worker returns home. When home health companies fail to respond quickly or staff properly, injured workers remain in the hospital, rehabilitation center or hotel for days longer than necessary – with the tab running.
The need for clear and fast communication with all stakeholders continues throughout the life of the claim. A care manager or coordinator—typically a registered nurse with additional certification—gives field and telephonic case managers, adjusters and other providers a single point of contact and provides clinical oversight of all aspects of the case. This coordinator provides peer-to-peer contact with clinicians, works with the family and injured worker, and makes sure that all stakeholders stay informed about the case.
Timely care depends on timely communication yet some adjusters wait two weeks or more for home visit reports. This delays their ability to make decisions and initiate care. In today’s world, there’s no reason to wait. A field provider can use a mobile app to produce a status report that goes to the claims manager on the same day. Real-time reporting can cause a prescription to be ordered right away or have a piece of DME delivered to the home to help the injured worker recover faster.
Using telehealth technology, a clinical care coordinator can examine a wound, see how care is being delivered and suggest changes, conferencing in the treating physician if necessary. Proactive care can prevent a skin integrity issue from deteriorating and sending the injured worker to the hospital. Plus, the system can send a report to all the stakeholders at one time while recording it in the file.
Technology can save time—and therefore money– in home modifications as well. Sometimes adjusters hesitate to authorize home modifications because they cannot understand the rationale for them. Photos do not always tell the full story and it can take days or even weeks to get answers from the contractors who are developing the plans.
Through a video conference, the adjuster can take a virtual tour of the home and ask the contractor questions and get answers in real time. Being able to see the home this way makes it much easier to understand the construction needs and challenges and how modifications will improve the injured worker’s function, access and independence. Telehealth technology gives adjusters greater transparency into the process, equipping them to authorize the changes without delay. The sooner the work commences, the sooner the injured worker can come home and stop the flow of invoices from an extended-stay hotel or rehabilitation center.
Other ways to control costs in home modifications include using a network of ADA-certified contractors who have experience renovating for injured workers. Inexperienced contractors may lower every light switch and widen every door instead of customizing the changes to the needs of the injured worker.
It’s best to pair the contractor with an occupational therapist or nurse case manager who understands the relationship of DME, modifications and nursing care and can create a plan that addresses functional status, medical conditions and accessibility barriers. A wheel chair with a narrow base may avoid the need to widen doors, and you need to make sure the ceiling can bear the weight of the prescribed lift. Some home health companies even retain experienced contractors to consult on tricky construction issues to prevent extra costs.
Prosthetics bring their own set of cost drivers, including delays in authorizations and treatment along with coding issues. If not assessed and fitted with a prosthesis as soon as healing occurs, an injured worker remains sedentary and the residual limb will not achieve optimal shape. If it takes weeks to schedule the initial assessment or authorize a quote, the injured worker may have to wear a shrinker again or end up using two or three artificial limbs before one fits properly.
Then there are the codes. Many of the components used in prosthetics lack specific codes and descriptions which allows manufacturers to assign any costs they want. Most claims managers do not deal with prosthetics often enough to recognize inflated prices. It takes a thorough review of the estimate by a neutral prosthetic orthotic (CPO) specialist, and these reviews can produce tens of thousands of dollars in savings. The CPO can also have a collegial, peer-to-peer conversation with the prosthetic provider regarding less expensive devices with the same functionality, reducing the costs even more. In fact, it is common for a combination of this specialized bill review and peer review to cut initial quotes in half.
Catastrophic claims should be reviewed every year at least to make sure the care being delivered is still appropriate and necessary. Sometimes medical supplies continue to be delivered even though they are no longer used. Could DME replace the need for 24/7 companion care? Are all the providers in the network or are there repricing opportunities? Is the current level of care still required? From a cost-management perspective, timely discharge or reduction in the level of care can be just as important as timely commencement of care.
It’s also good to benchmark the injured worker’s progress against available recovery data by ICD-10 codes. Obviously, there are brain injuries and quadriplegic cases that require lifetime care, but some catastrophically injured workers can recover and return to work. Collecting and analyzing treatment and recovery data enables payers to measure their results against ICD-10 benchmarks and calculate savings or explore other treatment options.
With home health, as with other types of managed care, savings depend on injured workers receiving the right care at the right time at the right cost.
About Vonesa Wenzel
A co-founder of HomeCare Connect, Vonesa Wenzel oversees the company’s sales, marketing and product development. HomeCare Connect’s growth is based on Wenzel’s strategy of probing for pain points, thoughtfully listening to concerns expressed by customers, prospects and other stakeholders, and creating services to fill unmet needs. She aggressively seeks ways to eliminate waste, reduce delays and facilitate timely, high-quality home health care
She started her career as a Sales Representative for a field case management company, becoming its Vice President of Sales by the age of 31. Later, Wenzel co-founded ZoneCare USA, a workers’ compensation transportation and translation service provider, and helped grow it into a $30 million company within eight years.
Wenzel holds a Bachelor of Science degree in Communications from Georgia Southern University in Statesboro, Georgia and can be reached at email@example.com.
About HomeCare Connect
Specializing in catastrophic cases, HomeCare Connect focuses exclusively on managing the quality and cost of home health, durable medical equipment and supplies, prosthetics and orthotics, and home modifications for workers’ compensation payers. With more than 17,000 contracted network providers, its services include nursing, home infusion, respiratory therapy, speech and occupational therapy, prosthetics and orthotics, and the coordination of DME and supplies along with managing home modifications. HomeCare Connect’s partners consolidated their 20-plus years of workers’ compensation experience into offerings and service standards that ensure that injured workers receive excellent care in the fastest time frames at the most affordable prices. Ranked on Inc. Magazine’s list of fast growing privately held companies, HomeCare Connect serves clients nationally and can be reached at www.homecareconnect.com or 855-223-2228.
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