By Ted Smith, Senior Vice President, Apricus
In workers’ compensation, catastrophic (CAT) injuries occur with relatively low frequency. However, when they happen, payers demand an all-hands-on-deck approach that can benefit from specialized experts to manage specific aspects of these complicated claims.
To address this, some payers have established their own internal catastrophic claims teams, engaging their most seasoned claims professionals to manage these types of injuries. These adjusters are highly experienced in managing catastrophic claims. However, they are often handling multiple catastrophic cases at the same time — all of which have numerous complicated and, often, urgent moving parts. Similarly, an assigned CAT case manager provides immediate clinical intervention and helps manage the clinical care and return-to-work components of these cases.
Specialty Service Providers and Catastrophic Injuries
The value of specialty networks is not new to workers’ compensation. Whether an injured individual needs to step down from acute care to a rehabilitation facility, or needs durable medical equipment (DME), transportation, translation, home health services, diagnostics, home or vehicle modification — there are many services to coordinate. When it comes to catastrophic cases, the benefit of incorporating a specialty service provider to collaborate with the catastrophic team and coordinate the specialty services needed is even more evident.
Payers may not realize how beneficial a specialty care coordinator can be when an experienced catastrophic claim team is already in place; however, highly experienced specialty care coordinators manage the logistics and communication of specialty products and service procurement, allowing adjusters and case managers to focus on patient care and returning the individual to their pre-injured state or maximum medical improvement.
Claims adjusters and CAT case managers benefit from working with a specialty service provider who effectively coordinates and communicates across various touchpoints. Working with the claims adjuster and case manager, specialty care coordinators take a patient-centric approach to ensure the best-possible service, results, and costs, as well as a seamless continuum of care for the injured employee. This is most vital as the injured individual makes critical transitions — for example, from hospital to another facility, or from facility to home. Below are some of the key considerations for engaging a specialty care coordinator for your catastrophic care team.
Early Intervention That Includes a Game Plan
Seamless coordination and communication ensure injured employees have the essential products and services at each stage of care and recovery. This involves expert-level engagement from the start of the claim. The earlier a specialty service provider is brought on to the catastrophic injury case, the earlier specialty care coordinators can begin their time-sensitive coordination.
Once a specialty service provider is engaged, the specialty care coordinator begins to communicate with key stakeholders — whether the adjuster, treatment team, discharge staff or CAT case manager — to ascertain the injured employee’s specialty service needs.
In most catastrophic cases, the injured employee is hospitalized. From that point forward, the specialty care coordinator works with the adjuster and CAT case manager to outline the successive services, equipment, and supplies that might be needed upon discharge. Due to the volatile nature of catastrophic injuries, this plan must remain flexible to accommodate the patient’s evolving needs. As such, it’s important that the specialty care coordinator be nimble and adept at ongoing communication and coordination.
Another key component of the plan is cost transparency, which is vital for the adjuster to accurately set reserves. A flexible specialty service provider works with any medical management company; however, a payer may prefer a more integrated approach that combines the management of medical and specialty services. Having one specialty care coordinator able to facilitate this can have a profound, positive impact on catastrophic claims costs and outcomes.
At each touchpoint, the specialty care coordinator communicates with the claims adjuster and case manager to ensure all stakeholders are aware of necessary equipment, supplies and services, and ensure critical items and costs are approved along the way.
Proactive Hospital Discharge
Prior to discharge, the specialty care coordinator works with the CAT case manager and hospital staff to understand the injured employee’s discharge plan. The specialty service provider asks the questions needed to understand the patient’s comprehensive needs. For example, the specialty care coordinator finds out if the injured employee requires transportation home or to a different facility, and if so, schedules that service. The care coordinator also assesses the type of transportation, such as a wheelchair or stretcher transport, depending on the severity of the injury.
Additionally, the coordinator understands if the patient requires a skilled nursing or inpatient rehabilitation facility, or if the patient requires home or vehicle modifications allowing for a successful transition home and improved ability to get around.
Finding the Right Facility & Negotiating Costs
If the injured employee requires a facility for further care, recovery and rehabilitation, the specialty care coordinator matches the type of injury to the best facility. A full-service specialty service provider has a national network of qualified facilities, and also has the capability to reach out to non-network facilities to identify the best match for the particular type of injury. In such instances, the specialty care coordinator will negotiate pricing and outline what’s included in the negotiated rate.
Coordinating the Return Home
When the injured employee is ready to be discharged from the hospital or facility, the specialty care coordinator works with the CAT case manager, as well as hospital or facility staff to understand when discharge will occur and what specialty services are immediately required for the return home and long term. For those transitioning home, specialty care coordinators ensure all necessary details are arranged, ranging from equipment, to supplies to home.
The specialty care coordinator cross-checks this plan against evidence-based guidelines, collaborates with the CAT case manager, and presents it to the adjuster for approval before proceeding with coordination. A key value the specialty care coordinator offers is the ability to manage all the requirements proactively and within the appropriate timeframe, so the equipment, modifications or other services are in place when the injured employee arrives home or, otherwise, needs them.
Extensive Home or Vehicle Modifications
As mentioned previously, some catastrophic cases require home or vehicle modifications. As with any home project where a contract is necessary, the specialty provider obtains several quotes. The specialty care coordinator checks references to verify the quality of the work and the estimated price. The coordinator may also work with several contractors to ensure an overall cost-effective modification is performed. In addition, the adjuster may need estimates broken down by materials and labor or want to know project costs by room or to know how much specific items will cost.
While it’s the payer’s role to make modifications that accommodate the employee’s injury, these modifications should be at a level comparable to what was in place before the modification. Working with an experienced specialty care coordinator who understands this need for cost containment and transparency can make this process more efficient for all parties involved.
Improving Adjuster Workflows
In terms of specialty services, catastrophic injuries require the timely coordination of multiple types of products and services. A great specialty care coordinator is skilled at assessing the injured employee’s situation and strategically coordinating delivery, so items and services are in place.
Adjusters can offload this function with tremendous benefit to their stretched workload. Entrusting an experienced specialty service provider to assume the administrative and logistical burden allows the adjuster to focus on the big picture. This is a huge advantage for adjusters, who are already burdened with numerous catastrophic cases and many important tasks to manage.
About the Author
Ted Smith is senior vice president for Apricus. With more than 10 years of experience in the workers’ compensation industry, Ted is an expert on managing specialty services, including diagnostics, durable medical equipment (DME), and home health services.
About Apricus, an Enlyte Company
Apricus is a specialty solution provider with long-standing industry roots and partners. We are the combination of two industry-leading specialty programs offering durable medical equipment, diagnostic imaging, physical medicine, home health, transportation, translation, and more to the casualty insurance market. Every day, Apricus works to coordinate the most effective injury-recovery services for those who have been hurt in an accident.
Apricus parent Enlyte is a WorkCompWire ad partner.
This is NOT a paid placement.