Compmed Advantage - Case Management

CASE MANAGEMENT

The CompMed Partnership’s case management process is comprehensive with a goal to ensure timely provision of medical care, early return to work at reduced costs to the employer or carrier. The effective management of the healthcare process to the injured worker is critical to early and effective recovery of the employee as well as reducing lost time and overall costs to the employer. This management process should not represent an emphasis on the healthcare delivery system or controlling costs as its main objective, but if properly managed, can meet both goals effectively to the benefit of both parties.

It is The CompMed Partnership’s objective to offer a case management product that accomplishes the above both through either its Indemnity Cost Reduction Program or its traditional case management products.

For a detailed description of the traditional case management process please see below. The cost reduction program ( offered with traditional pricing or on a risk sharing basis ) is discussed in a previous selectable category in this section.

Case Management Process

Purpose/Brief Description: To ensure prompt medical treatment and care of injured workers. This is a collaborative process that assess, plans, implements, coordinates, monitors, and evaluates options and services to meet the claimant’s health care needs.

1. NOTIFICATION:

Notification that an accident or illness has occurred, and needs immediate medical attention will come via the 1-800 #. The Nurse Case Manager will initiate the “Intake Record” for all new injuries during normal business hours. After hours the Intake Record will be completed and the process managed by the on-call staff nurses in Occupational Medicine and referred to the Nurse Case Manager on the next day of business.
2. INTAKE RECORD REQUIREMENTS:
a. Obtain demographic information on employee.

b. Complete all information on the Intake Record.

c. Record a detailed description of how the injury or illness occurred.

d. Record chief complaint.

e. Obtain a brief medical history including medications, allergies, any previous injuries sustained on or off the job, surgeries and major illnesses. Obtain dates of these occurrences and treating physician whenever possible.

f. Obtain three (3) year Occupational History.

g. Inquire about activities the person engages in outside of work, i.e. other jobs, hobbies, sports.

h. Remind employee they must file an injury report with their company according to their company’s policy and procedure.

i. Using the information obtained during the intake process, determine the likelihood of the work environment causing the reported injury or illness.

3. ASSESSMENT AND REFERRAL:

a. Determine level of care needed and schedule appointment. If the employee has a primary care provider that is a member of a contracted network, they may be seen by that office. If the claimant does not have a primary care provider, offer a pre-identified Occupational Medicine clinic as an alternative.

b. All attempt should be made to schedule appointments around the employees work schedule, but the timeliness of the appointment is critical with the goal of 48 hours at a maximum.

c. If the appointment does not meet the time requirements due to the medical office scheduling constraints, make every reasonable attempt to reschedule to an earlier appointment. If that is not successful, immediately notify the Nurse Manager and/or Executive Director, Business Direct for intervention and document in SYSTOC (Injury Management Software).

d. When calling the physician office and identify employee as a workers’ compensation managed care client and alert them to complete the “Patient Management Record.” Advise them the record should be faxed back within 24 hours from the time of the visit.

e. After scheduling appointment, fax a copy of the Patient Management Record with the completed patient demographics to the treating physician’s office.
4. PROGRESS REPORTING:
a. Coordinate communication between all parties, i.e., employer, claims adjustor, and employee. The frequency of this communication must be with every employee interaction or visit.

b. Communicate with the employer, claims adjustor via mechanism determined to meet their needs, i.e., fax, mail or email. This would include all necessary information to manage the claim.

c. Inform the employer and claims adjustor, upon receipt of employee notification of an accident or illness, and the details of the scheduled medical appointment.

d. Advise the employer and claims adjustor, of any concerns or “red flags” if they are present. Request the company identify any issues or concerns from their perspective. Examples of a “red flag” would be a claimant with late reporting, seeking medical care from multiple providers, not returning phone calls when totally disabled from work, and an employee is a no show to scheduled appointments.

5. CASE MANAGEMENT FOLLOW-UP:

a. Call the employee after all medical provider visits to assess employee’s level of understanding of medical treatment. Periodic follow up is required at a minimum of every two (2) weeks.

b. Obtain Patient Management Record form from the medical provider office. This is the primary tool the case manager will use to follow the treatment plan for the injured employee.

c. Communicate to the employer and claims adjustor, the results of the medical visit. Include any requests for physical therapy, diagnostics, or surgical requests and date of next scheduled appointment. This is to be followed with written documentation, via fax, mail or email.

d. The Nurse Case Manager will request authorization for the initial (six or twelve) Physical Therapy/Occupational Therapy (PT/OT) visits as appropriate. Any additional requests for PT/OT will be determined by the Nurse Case Manager and claims adjustor after review of the notes. The Nurse Case Manager will telephonically communicate with the claims adjustor all additional requests, for their approval or denial. The claims adjustor will provide approval or denial of additional services within twenty four (24) business hours of such request.

e. Obtain OT/PT initial evaluation note within 5 business days, and review assessment, prognosis, treatment recommendations and plan. Additionally, obtain PT/OT notes every two (2) weeks, and again review employee’s status. All notes are to be forwarded to the provider and claims adjustor.

f. Collaborate with Medical Director as needed for further direction and assistance to achieve best claimant outcomes.

6. RETURN TO WORK:

a. Whenever feasible, a work-site walk through will be completed on new accounts so all have knowledge of the employers’ work requirements.

b. Job Assessments identifying the essential functions and physical requirements for each job will be completed.

c. When an employee is assigned work restrictions, communicate specifics to the employer and determine if the employer can accommodate the restrictions. Assist employer in identifying appropriate work duties that are within the restrictions and update accommodation status to the claims adjustor.

d. Document the work status and future treatment in SYSTOC. For tracking of restricted duty days and company accommodation, the dates and status are entered into SYSTOC.

7. UTILIZATION REVIEW:

a. Review physician referral and authorization requests, compare with treatment practice parameters for that particular diagnosis, and discuss treatment request with the claims adjustor. The claims adjustor will issue an approval or denial within 24 (business) hours of the request for authorization.

b. Supporting reasons for authorization or denial must be communicated to the claims adjustor and employer and documented in the SYSTOC case notes.

c. The Nurse Case Manager will schedule all appointment(s) for requested procedure, test or treatment. (Some insurance carriers use One Call Medical or Medfocus to obtain reduced rates on MRI’s). Additionally, some of these vendors have the ability to perform chronicity studies, which determine if clinical findings on the MRI are related to the employee’s injury date.

e. All hospital admissions are to be reviewed in a focused manner to reduce the length of stay of an inpatient admission, if possible. All hospital admissions are to be evaluated preferably on the day of the admission at the admitting hospital. The Nurse Case Manager will also assist in discharge planning; including referrals, and Durable Medical Equipment (DME) needs to ensure safe and timely hospital discharge.

8. CASE CLOSURE:

a. Follow up is to occur until the employee is released from medical care, or if the workers’ compensation claim is controverted, the employee is terminated from employment (unless client has signed a C3.1 form).

b. Case closure is documented in SYSTOC and the claims adjustor, employer and employee are always made aware the claim is closed for medical management.

9. CASE REVIEWS:

a. Case reviews of claims activity will be performed monthly between the Nursing Manager and the Nurse Case Manager.