Presentation To
South Texas
ASSE
San Antonio, TX
Presentation Summary
¾ Corporate Overview
¾ Essentials of Workers’ Compensation Law ¾ Red Flags of Questionable Comp Claims ¾ Influencing the Outcome of Your Claims ¾ Using Case Management to Save $$$$ ¾ Q & A
¾ CasePro was founded August 1, 1996 ¾ Woman-owned
¾ Certified as WBE by the SCTRCA, and as SBE, DBE and WBE by NCTRCA
Two Divisions
¾ Disability Management Division ¾ Federal Contracting Division
Multi-State Operations
¾ Seven core states in Disability Management Division
Experienced Management Team
¾ Shirley Hill, RN, CRRN, CCM
President
20 Years in Healthcare Management ¾ John Hill, CPA
Executive Vice President
30 Years in Corporate Finance and Accounting ¾ Michael McCabe, BS Engineering, MBA Finance
Senior Vice President, 15 Years Multi-National Corporate Experience
Your Presenter
¾ Nancy Lewis, BS, MS Psychology, CRC
Vice President, Disability Management 27 Years Providing Rehabilitation Services ¾ (210) 496-8050/nancy@caseproinc.com
Other Members of the CasePro Team
¾ Registered Nurses
¾ Vocational Rehabilitation Consultants ¾ Life Care Planners
Overview of
Texas Workers’
Comp Law
General History of Workers’ Comp
¾ Grew out of the Industrial Revolution ¾ Protects employer from being sued
¾ Provides wage replacement (indemnity) and medical care to eligible IW, i.e., claim must be compensable
Texas Law Employer Driven – 1/2006
¾ TWCC replaced by Division of Workers’ Compensation ¾ DWC oversees administration of comp rules and
regulations
¾ Employers can now elect for injured worker to treat within a Physician Network
Types of Comp Coverage
¾ Fully insured ¾ Large deductible ¾ Self-Insured ¾ Self-Funded ¾ Non-SubscriberTypes of Benefits
¾ Medical benefits
¾ Temporary Income Benefits (TIBs) ¾ Impairment Income Benefits (IIBs) ¾ Supplemental Income Benefits (SIBs) ¾ Lifetime Income Benefits (LIBs)
Settling Disputes
¾ Benefit Review Conference (BRC) ¾ Contested Case Hearing (CCH)
¾ IW can request representation by DWC ombudsman or may be represented by plaintiff attorney
¾ Employer can be present at BRC and CCH and is represented by claims adjuster as well as defense attorney if they wish
1. File Open More than Six Weeks
¾ Most back injuries resolve within six weeks, with or without care
2. Catastrophic or Multiple Injuries
*
¾ Probability of prolonged time off work with considerable medical expense
¾ Need for highly skilled, specialty medical care
*
Catastrophic claims should always be referred for case3. Co-Morbid Conditions
¾ Smoking ¾ Diabetes ¾ Hypertension ¾ Overweight ¾ Drug abuse4. Choice of Treating Physician
¾ Physician’s specialty and strengths ¾ Physician’s focus—IW or employer?
¾ Physician’s willingness to meet and work with case manager
5. Treatment Plan Appropriate?
¾ Conservative care vs premature diagnostic testing or more invasive treatment
6. Lack of Objective Findings
¾ Objective testing should support subjective complaints ¾ Complaints without objective findings suggest symptom
magnification and/or secondary gain
7. Positive Waddell’s Signs
¾ Tests performed by MD revealing “non-physiologic findings”
8. Any Misrepresentation of Facts
¾ IW may represent condition as worse than it is
¾ IW may mislead physician regarding job demands*
9. Injured Shortly After Being Hired
¾ May indicate pre-existing condition for which IW is seeking treatment
10. History of Work Injuries
¾ Past injury may be cause of current complaints ¾ Or may be indicative of a “professional” claimant
11.
Non-compliance With Medical Care
¾
Typically occurs with less serious injuries ¾ Suggests lack of commitment to recovery ¾ Secondary gain may be involved12. Injury Occurring on Monday
¾ May indicate injury actually occurred over weekend
13. Injured Worker Has Personal Crisis
¾ Frequent correlation with more extensive disability
14. Excessive Use of Medications
¾ May be utilizing claim for drug seeking
15. History of Recent On-Job Discipline
¾ Claim may be retaliation
16. Injured Worker Adversarial
¾ Often has prior workers’ comp experience ¾ May be trying to drive up value of claim
¾ Usually a demanding and manipulative personality
17. Attorney Involvement
¾ Motivation to resolve claim and return to work questionable
18. Symptom Magnification
¾ Failure to respond to conservative care
¾ Complaints unsupported by objective findings
¾ Often prolonged chiropractic care or excessive physical therapy
¾ May be attempt to prolong time off work
19. Additional Diagnosis Secondary to
Injury
¾ Such as back pain secondary to knee pain or ¾ Any kind of psychological (functional) overlay
20.
Surgery Recommended Without
Objective Findings
¾ Suggests physician may not be objective
¾ Suggests secondary gain or ignorance on part of IW
21. History of Psychological Problems
¾
Typically prolongs claim due to secondary gain issues ¾ Family dynamics22. Repetitive Trauma
¾ Treatment may be prolonged and include surgery ¾ Work station or job duties may require modification
23. Injured Worker Refuses Bonafide
Job Offer
Influencing the
Employer Must Take The Initiative
¾ Maintain contact with IW—communication is key
¾ Hold claims handler and other team members accountable ¾ Create effective return-to-work program
¾ Recognize Red Flags
¾ Involve ancillary services (i.e., case management or private investigator) when appropriate
Communication is Key
¾ Positive contact with IW helps minimize time off ¾ Should be from supervisor or other manager
¾ Demonstrates genuine concern for and value of employee ¾ Helps offset negative influences
Manage Your Team Members
¾ They work for you and:
¾ Should be responsive to you and IW
¾ Should be dedicated to your account whenever possible ¾ Should recognize and promote your values
Facilitate Modified Duty RTW
¾ Studies show IWs off work for more than 6 months are unlikely to return to any job ever
¾ DWC Reimbursement Account for small employers helps cover costs of job modification (see handout) ¾ Modified duty saves employer money
Recognize Red Flags
¾ Red flags—heads up for problem claims with potential for prolonged time off work and higher costs
¾ May require greater vigilance on your part
¾ May indicate need to mobilize ancillary services such as case management
What is Case Management?
¾ Service provided by medical and vocational rehabilitation professionals who are:
¾ Representing your interests
¾ Assisting IW navigate medical and comp systems ¾ Facilitating rapid return to work
Two Types of Case Management
¾ Medical Case Management (MCM) ¾ Vocational Case Management (VCM) ¾ Either can be telephonic or field
MCM Should be Medical Pro
¾ Typically RN or with related degree
¾ Possesses years of medical and/or case management experience
¾ Expertise supported by national certifications such as CCM, CRRN, CRC or CDMS
Keys to Good Medical Case Management
¾ Sound medical knowledge
¾ Understanding of the law and its implications ¾ Excellent negotiating skills
¾ Ability to think like the account ¾ Knows when to close the file
Medical Case Management
¾ Should be involved early in life of claim
¾ With focus on resolving medical issues and limiting impairment
MCM Helps Resolve Claim By
¾ Assessing medical status
¾ Facilitating and coordinating appropriate medical care ¾ Holding medical providers and IW accountable
¾ Promoting communication between all parties ¾ Expediting return to work
VCM Should be a Vocational Rehab Pro
¾ Typically has MS in rehab studies or related field
¾ Or may be a RN with appropriate on-the-job experience ¾ Expertise supported by national certification such as CRC,
CCM, CRRN, CVE or CDMS
Vocational Case Management
¾ Assigned to IWs receiving 15% or greater impairment ¾ With focus on demonstrating access to the labor market
and facilitating return to work ¾ To limit eligibility for SIBs
VCM Helps Resolve Claim By
¾ Identifying IW’s vocational interests and abilities, then ¾ Creating a Rehabilitation Plan and initiating job search ¾ While coaching IW in job seeking skills
¾ With goal of achieving return to work
¾ And limiting or preventing eligibility for SIBs ¾ Resulting in cost savings for you
Case Managers Represent Your Interests By
¾ Knowing your corporate values and goals
¾ Promoting those values and goals whenever possible ¾ Acting as your eyes and ears in the field
¾ All the while moving your files toward closure ¾ For the bottom line purpose of saving you $$$$
Good Case
Management =
Cost Saving
Glossary of Terms
(see handout)
