By Judith Speirs, MA, CRC, CDMS, NCC, Senior Product Manager in Case Management Product Development at Genex Services
When you walk into a restaurant for breakfast, you can quickly get a sense of the experience ahead. The host offers you a warm welcome. You’re shown to a clean table and your order is promptly taken and precisely conveyed to the kitchen, so your eggs arrive just the way you like them. The wait staff makes certain your cup is continually filled and that you have all your favorite condiments. Soon, you’re on your way, hunger satisfied and a smile on your face.
Behind operations like this one are experienced staff, quality standards, and training – all of which make you want to come back and become a loyal, repeat customer. In workers’ compensation, the service provided around an injury claim – while it is a more complicated transaction – should run just as smoothly. On complex injury claims, assigning a case manager goes a long way toward ensuring quality care, optimal medical outcomes, a satisfied injured employee, and an expedient return to work (RTW).
Similar to the breakfast scenario, a claims organization can quickly tell whether a case management provider has quality standards in place – and on the flipside, when they don’t. One of the surest indicators of poor quality is that your claims staff is ringing the case management’s service department with complaints: Why hasn’t this case progressed? Why hasn’t the injured employee returned to work? Why hasn’t this individual been weaned off opioids?
With 40 years in the workers’ comp industry, I’ve had a lot of experience in building and overseeing quality assurance programs in case management, and there are red flags that indicate when quality has gone awry. In this article, we’ll review five frequently seen examples and, by contrast, discuss how a case management program with strong quality management operates. This is by no means a comprehensive list but aims to outline common examples.
1. Lack of timeliness and delays.
An immediate red flag that a claims department might notice in regard to quality is a lack of timeliness around expected case management activity. For example, perhaps a file isn’t assigned to a case manager in a timely fashion, or once assigned, the case manager doesn’t communicate with the adjuster promptly. Reports and updates fall behind anticipated timeframes. Together, these little lags add up to significant delays and, ultimately, it’s the injured employees who could suffer by not getting the care and services they need on a timely basis.
A case management company with a quality program will have benchmarks in place to measure and ensure tasks occur within appropriate timeframes for activities like assigning referrals to the right case manager and performing the initial points of contacts. Audits also occur to confirm the standards are consistently being met – and if not, corrective actions will be taken to rectify the problem.
2. Treatment and recovery don’t seem up to par.
Many times, adjusters have handled similar cases or have a general sense of evidence-based guidelines, so they know when a case isn’t progressing as it should. They may wonder: Is the case manager being proactive enough? Is he or she pushing the physician to get the injured employee the care they need to facilitate recovery and return to work?
A quality management program ensures that case managers conduct a thorough initial assessment and develop a comprehensive plan for the case. This includes:
- Comparing the treatment plan against clinical guidelines – and communicating with the physician when it’s not in sync to better understand why.
- Communicating with the injured employee, adjuster, and physician regarding short- and long-term goals for the case.
- Serving as a patient advocate to ensure injured employees obtain the care and services they need and conveying other recommendations to the adjuster.
- Asking the injured employee questions to determine if psychosocial or cultural issues may exist that could slow down or create other needs in the treatment plan.
3. A claims adjuster feels unaware of where a case stands.
A vital part of a case manager’s role is keeping the adjuster abreast of significant case activity. If an adjuster doesn’t feel “in the know” on a case, this may be another instance where cracks exist in a quality program.
Case managers should be both experienced and trained on how to provide adjusters with ongoing updates, reports, and documentation, so adjusters are always aware of what’s happening and when they’re coming to milestones in the case where important decisions may need to be made to push it forward.
4. Issues with medications.
Use of medication continues to rise and, with it, an increased need to manage this trend to control costs and, more importantly, ensure patient safety. Billions of prescriptions are filled each year in the U.S. – this includes similarly high usage in workers’ comp. Due to the nature of work injuries, pain is a common symptom, and opioid painkillers are often prescribed to manage this pain. A quality program provides a systematic framework to ensure case managers will:
- Evaluate initial and ongoing medications, both prescribed and over-the counter (OTC), as well as both injury and non-injury medications.
- Ensure the injured employee is educated on medication safety issues.
- Perform medication reconciliation, a process that helps prevent harmful interactions and adverse drug events. The process includes inventorying drug names, dosage, frequency, and route, and comparing the medical record to the external list of medications obtained from the injured employee, treating physician, hospital, and other providers.
- Evaluate narcotics and opioids if prescribed. This includes addressing with the prescribing physician any issues regarding weaning, urine drug testing, and obtaining a signed narcotics contract from the physician.
5. Delayed return to work.
If adjusters feel complex claims often experience inappropriate delays in RTW, this could point to quality issues – although it’s important to note that RTW is one area where close collaboration with the employer is key. If employers have a highly structured RTW program, they often experience good results with reduced lost days. And case managers play a significant role in executing the many behind-the-scene details that support this process.
For example, they will secure a job description or job analysis from the employer and provide it to the treating physician, who can then review specifics on the employee’s essential job functions. A comparison can be made between the injured employee’s work abilities and restrictions and the job description / job analysis to determine whether part of the person’s position can be performed, either in a light duty or modified duty capacity.
Case managers communicate with the employee’s manager to secure an RTW agreement. They also speak with the injured employee about RTW expectations, job tasks that match their abilities, and any additional concerns. With this type of approach, the case manager’s proactive communication with all parties makes the overall RTW process run smoothly.
And if RTW is not yet an option, the case manager may advocate for more physical therapy, work hardening, or job coaching, depending on the individual’s needs.
A Checklist for Quality in Case Management
Beyond the common red flags above, claims departments should look for four key components that demonstrate a case management company’s commitment to quality:
- The vendor should have a well-documented internal quality management program with specific standards and measurement criteria that help to evaluate, monitor, and improve the output of the case management operation. This should include performance measures for adhering to customer-specific guidelines.
- Case management staff must meet specific educational and/or experience requirements. In addition, the company should have a number of professional staff who are credentialed in specific professional areas that support case management excellence.
- The organization should adhere to national standards of practice such as those outlined by the Case Management Society of America (CMSA).
- And finally, the organization should have professional accreditation in case management as offered by the Utilization Review Accreditation Commission (URAC).
While we have discussed a myriad of quality standards that should occur on the case management company’s side of the operation, a quality process does require the close collaboration of all stakeholders, including the physician, employer, claims organization, and injured worker to make the entire workers’ compensation claims experience a success.
About Judith Speirs
Judith Speirs, MA, CRC, CDMS, NCC is a Senior Product Manager in Case Management Product Development at Genex Services. She joined Genex in 1982 as a vocational case manager. She has worked as a manager and multi-state regional director. For the past 19 years, she has been involved in quality management, training development and delivery, and accreditation of telephonic and field case management. She has an extensive background in vocational case management, including disability. She has served as an expert witness and overseen case management in the private sector. Her prior experience was in the area of adult and juvenile corrections in Colorado, working in both lock-down and halfway house facilities, providing both substance abuse and vocational counseling.
About Genex Services
Genex Services (www.genexservices.com) provides best-in-class clinical solutions that enable customers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex, a clinical management leader throughout North America, serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex clinical services are enhanced by intelligent systems and 360-degree data analysis. Its clinical expertise 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. Genex, Mitchell, and Coventry have recently combined their joint industry expertise and advanced technology solutions into one organization to simplify and optimize property, casualty and disability claims processes and services.
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