Customer Resources // Nurse Case Management

Red Flag List

Appropriate Referrals for Case Management Services

Medical Factors

• Disability period exceeds initial period indicated by physician
• Medical reports indicate stability, but return to work release not given
• Length of disability appears inappropriate for diagnosis
• Continuous medical / chiropractor treatments without documentation of improvement
• Back pain / injury treatment lasting over 45-90 days without a specific medical treatment plan documented
• Aggravation of a pre-existing medical condition
• Failed and / or repeated surgeries
• Pain out of proportion to the type of injury claimed
• Any of the following diagnoses:
  • Herniated disc requiring surgery
  • Low back pain without a specific diagnosis
  • Rotator cuff tears
  • Brachial plexus injuries
  • Thoracic outlet injuries
  • Carpal tunnel syndrome or de’Quervain’s syndrome
  • Fractures of the pelvis / hip
  • Complex fractures
  • Compression fractures
  • Trauma requiring plastic surgery
  • Ligamentous knee injury
  • Stress disorders/(PTSD)
  • Complex Regional Pain Syndrome (RSD)
  • Fibromyalgia
  • Known history of substance abuse

Catastrophis Factors

Needing Immediate Referral to Case Management Services

• Multiple trauma / fractures
• Burns
• Spinal cord injuries
• Head injuries
• Amputations of an extremity or multiple digits
• Injuries resulting in a paralysis or partial loss of sensation / motion
• Puncture wounds involving the chest / lung, abdomen or face
• Chemical inhalation
• Massive infection
• ICU admission
• Emergency In-Patient hospitalization

Case Management Benefits

“Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.”

–Case Management Society of America

According to the National Council on Compensation Insurance, claim costs decrease by 22% when medical management is utilized, and managed claims close 27% faster than unmanaged claims. The majority of employers report that Case Management programs are effective in dealing with disability. However, companies are often more aggressive in managing job related incidents than those that occur away from the job. While 47 percent track return-to-work results for a workers’ compensation injury or illness, only 19 percent do so for a non-occupational incident.

–Watson Wyatt

Case Management

Case Management characterized by both reduced costs and quality outcomes does not just “happen”. It requires planning and forethought. Comprehensive Case Management is performed at several different levels of intervention with various degrees of involvement and activity. These services are designed for the common purpose of managing the expenditure of claims dollars; however, each provides specific benefits.

Telephonic Case Management

Telephonic Case Management Services are available and generally utilized in an Early Intervention capacity. However, telephonic services may be utilized during any phase of the case management process when deemed appropriate for cost containment efforts.

Task Assignment

The Case Management product with most limited level of involvement. Task assignments are generated for the purpose of accomplishing one or very few specific activities and are used most often in conjunction with a customer’s in-house telephonic case management unit.

Full Case Management

Typically utilized when factors prolonging claims resolution are present. Full Case Management provides a comprehensive exchange of information and coordination of Case Management activities between the client, employer, medical provider(s) and payor. The Case Manager functions as a liaison and facilitator toward the goal of maximum medical improvement and successful return to work in a modified or full duty position.

Peer Review

(work relatedness) – the process of physician review to determine whether or not a condition or injury is related to a work accident; this often assists in determining compensability of a workers compensation claim

Medical Bill Audit - ASC

Medical bills are reviewed by experienced Registered Nurses to ensure compliance with the Worker’s Compensation Billing Criteria for each state. The bills are then reviewed to ensure that all charges are supported in the medical record and for relatedness.