On Allison’s first day as a case manager for a workers’ compensation insurer, her new employer had been impressed with her nursing experience as a case manager for an HMO and felt her skills would be an asset to the company. Allison shouldn’t worry about getting started, they explained; a case manager, experienced in workers’ compensation and occupational health, would be responsible for Allison’s orientation.
Allison’s mentor handed her a folder that included notes, assessments, and summaries to use as reference. Allison realized she was in uncharted territory when she came across abbreviations and acronyms she had never seen before:
“This IW, since FROI, has complained of LBP. The EE has been with ER since DOH on 1/1/02. PP is the local OH. RTW on LD until FCE, which could identify WC. If not, IME may be of benefit. Next OV with MP may give anticipated time of FD/FT release. MMI & PI to be determined at a later date.”
CLICK HERE FOR A LIST OF IMPORTANT ACRONYMS
“Uh-oh,”Allison thought. “I don’t understand a word of this.” Not to worry, though. This code is really no mystery. It is insurance language with terms she needed to learn.
Translation: This injured worker, since first report of injury, has complained of low back pain. The employee has been with (the) employer since (the) date of hire on Jan. 1, 2002. (The) preferred provider is the local occupational health (physician). (The injured worker will) Return to work on light duty until (the) functional capacity evaluation, which could identify work capacity. If not, independent medical examination may be of benefit. Next office visit with (the) medical provider may give anticipated time of full-duty/full-time (work) release. Maximum medical improvement and permanent impairment to be determined at a later date.
In the weeks to come, Allison learned the ropes. Her immediate team of adjusters, associates, and managers was supportive, answered questions, and welcomed her as part of the team. She realized that other nurses entering this field would appreciate some basic instruction before they landed their first job. Allison had been sure of her case management skills in an HMO, but workers’ comp was a new challenge. She needed to do some research to answer some questions like “What is it?” “Where did it come from?” and “How does it work?”
Workers’ compensation legislation was the first U.S. no-fault legislation. Before 1911, when the first state laws were enacted, injured workers had to prove employer responsibility.1 However, the average worker couldn’t afford the cost of proof plus ongoing medical care. As industry grew, so did injuries in factories. Progressive thinkers pushed for a more equitable solution.
Today’s system of disability management and case management combined with preventive safety programs has evolved over a 30-year period beginning with federal recommendations in 1972.2 Essential reforms made case management and nurse involvement integral to a successful program. This entailed improving a fragmented system riddled with escalating medical costs. Benefits were standardized, and cost containment and equity between state regulations were addressed. Return-to-work programs to benefit employer and worker were introduced.
The basic twofold concept has remained intact since 1911. Regardless of responsibility, 1) the worker receives wage replacement and medical care for the work-related injury, and 2) the employer cannot be sued by the employee for wages and injury-related costs.
Your new role
The Bureau of Labor Statistics’ 2002 figures show close to 5 million recorded cases of nonfatal workplace injuries and illnesses. The largest category of cases, 13%, included sprains, strains, and tears. This was followed by injuries to the back at 7%.3 Slips and falls, respiratory problems, highway incidents, and even dermatitis are examples of other recorded injuries. The toll in lost productivity was more than 1.4 million days away from work.3
Enter the nurse. When a nurse case manager is involved, days away from work, or “lost time,” can be reduced without affecting quality of care. Care often is enhanced by the expertise the nurse brings to the case.
Nurses who become case managers in workers’ compensation come from varied backgrounds. According to the Commission for Case Manager Certification, “Case management is not a profession in itself but rather an area of practice within one’s profession; it is collaborative and transdisciplinary in nature.”4 Typically, nurses bring experience in occupational health, managed care, discharge planning, and home health to this position. Most employers require such experience. But no matter what your background is, nurses new to this arena often are mentored by experienced case managers.
Employers of case managers who focus on workers’ compensation include insurance companies, occupational health clinics, and specialty providers, such as orthopedists. The job title of “workers’ compensation case manager” is the most common, but others exist, such as “disability management coordinator” or “injury management facilitator.” Whatever the name, the employment requirements are similar; the nurse case manager is present for the worker as “a means for achieving client wellness through advocacy, communication, education, identification of service resources, and service facilitation.”4
Your new tools and techniques
Was Allison’s experience in case management going to help ease her transition into workers’ compensation case management? She was skilled in communicating with patients and medical providers on a regular basis. What could be different here?
Three case management methods are recognized as standard: telephonic, on-site, and combined. A telephonic case manager contacts all involved parties by phone, letter, or fax. On-site case managers visit injured employees and their workplaces and attend physician and treatment appointments. The combined method applies both telephonic and on-site techniques.
The telephonic approach relies on the cooperation of providers, the employer, and the injured worker. Often, the caseload is larger because the case manager doesn’t leave an office setting. To obtain the information necessary and achieve goals, a nurse case manager must possess a strong clinical background and use interpersonal skills that relate well telephonically.
The on-site approach requires face-to-face interaction. The caseload may be lighter because of the demands of frequent travel and the need to attend appointments. Strong clinical skills also are important, and the nurse needs to be able to create successful relationships dealing directly with workers, employers, and providers.
The combined method is just that: The caseload is a mixture of each type. Simpler, straightforward cases remain telephonic when the goals can be met in this manner. Files that are complex, possibly with catastrophic circumstances, may be managed with on-site visitation. Often, insurers use a combined approach to meet the varied needs of their clients.
Your team
The nurse case manager is an active contributing member of two interacting teams. The internal team usually consists of a claims adjuster and case manager. At times, there is interaction with other departments in the company, such as inside counsel, loss control, or underwriters. The external team consists of the injured worker, medical providers, and the employer. This external team is the source of your most valued information and the “three-point contact,” the basis of your daily workflow.
The two teams interact regularly. For example, the worker needs payment information and speaks with the adjuster. The adjuster calls the employer about weekly wages. The case manager obtains documentation from the provider on medical necessity and discusses authorizations with the adjuster. Most important, the case manager maintains consistent collaborative contact with the injured worker, employer, and provider to promote a safe and timely return to work.
Communication and cooperation are essential, and the case manager is the link. If issues exist between employer and employee about when the employee should return to work, the case manager may be able to mediate. The case manager can expedite care and treatment and act as an advocate for the worker.
Your tasks and workflow
Each file or case requires a “three-point contact,” another new term Allison needed to learn. Of course, contacting the injured worker is one contact. Then what?
The employer and medical provider join the injured employee as the three elements of a “three-point contact.” There are two three-point contacts: one by the adjuster, one by the nurse. Each has different perspectives.
The adjuster tries to determine causation, contributing factors, or compensability. This contact, performed within 24 to 48 hours of claim notification, is a requirement of many commercial insurers for their adjusters.5
The nurse case manager’s “three-point contact” deals with other issues. Specifically, the goal of case management is to “assess barriers to return to work, communicate with the employer and provide education on the positive effects of returning the injured worker to work; address medical concerns that may prevent return to work; and coordinate the return to work process.”6 A referral for case management can occur at any time during the life of a claim. Generally, sources of a referral are the employer, the claims adjuster, or the injured employee.
Before making contacts, the case manager needs to review the records for background information. The nurse’s initial calls to each of the three parties should be twofold: introduction and inquiry. The introduction creates the basis of the relationship that will evolve. In each case, the nurse case manager should seek to establish trust and confidence, and confirm that he or she will continue to be available during the course of the claim.
Inquiry provides information essential to the initial assessment, subsequent planning, coordination, and evaluation stages. This interview helps the nurse and others involved understand the injury, formulate a treatment plan, and research return-to-work policies and barriers that might hinder a return to work. Later contact, telephonic or on-site, is done to evaluate the success of the treatment plans. This contact is necessary to continue to assess the worker’s progress toward recovery and offers an avenue to continue to monitor status. The case management functions of assessor, planner, facilitator, and advocate continue throughout the nurse’s involvement with the injured worker regardless of prognosis and medical end point.
When Allison became a workers’ compensation case manager, she was introduced to a host of new acronyms. ER no longer meant emergency room. Depending on the circumstances, WC could related to workers’ comp or work capacity. In addition, each employer may have its own set of abbreviations to learn. (See chart for help.)
Many case managers new to a workers’ comp insurer have experience and skills directly relating to this position. New case managers often are placed with a mentor. Whether it is called orientation, mentoring, or even probation, a seasoned case manager usually is responsible for a successful adjustment to a new environment. This is the first opportunity to learn the basics of the company and workflow. A positive relationship with a mentor offers support and collegial assistance.
Other sources of information are available. The most prominent national professional organization is the Case Management Society of America [www.cmsa.org]. Regional chapters hold meetings and offer CE presentations, conferences, and networking opportunities. Certification programs can offer professional advancement; many workers’ compensation employers desire nurses to be certified in case management. Journals, newsletters, and reference materials are also available. It’s important to become familiar with industry standards. The Medical Disability Advisor: Workplace Guidelines for Disability Duration covers a wide range of illnesses and injuries, and duration guidelines to allow for individual differences in response to illness or injury.8
Anytime nurses change career paths, they must acquire new knowledge. Getting a jump on the learning curve before your first day on the job can be essential to your success.
About the Author
Jill Hancock, RN, AD, CCM, is a disability management consultant for the MEMIC Indemnity Co., a northeast regional workers’ compensation carrier in Manchester, N.H. (The author has declared no real or perceived conflicts of interest that relate to this educational activity.)
The author(s) has declared no real or perceived conflicts of interest that relate to this educational activity.
References
1. Wolf JF. Perspectives: a brief history of the Workers’ Compensation Act. Available at: www.422business.com/articles/200008/perspectivesabrief.html. Accessed May 10, 2004.
2. Hunt HA, Habeck RV. New Hope for Workers’ Compensation Programs. Kalamazoo, MI: WE Upjohn Institute for Employment Research; 1994.
3. U.S. Department of Labor. Bureau of Labor Statistics. Injuries, illnesses, and fatalities. Available at: www.bls.gov/iif/home.htm. Accessed June 3, 2004.
4. Commission for Case Manager Certification. Code of Professional Conduct for Case Managers. Available at: www.ccmcertification.org. Accessed May 10, 2004.
5. Brownlee K. Claims conscious — iconoclast claim philosophy. Claims Magazine: Covering the Business of Loss. August 2003. Available at www.claimsmag.com/Issues/Aug03/Iconoclast.asp Accessed May 10, 2004.
6. Powell SK, Ignatavicius D. Core Curriculum for Case Management. Philadelphia: Lippincott Williams Wilkins; 2001.
7. Jones JR, Maggio J. Managing Bodily Injury Claims. Malvern, PA: Insurance Institute of America; 1999.
8. Reed P. The Medical Disability Advisor, Workplace Guidelines for Disability Duration. 4th ed. Boulder, CO: Reed Group; 2001.
ACRONYMS
| Acronym |
Meaning |
Important to Know |
| IW |
Injured Worker |
One part of the three-point contact. These are only three of the terms you might see describing the injured.
|
| EEC |
Employee |
| C |
Claimant |
|
| ER |
Employer
(insured) |
Another part of the three-point contact. The employer is the policy holder that provides the medical benefits for the injured worker.
|
|
| MP |
Medical provider |
The third member of the three-point contact: a physician, therapist, home health nurse, or others.
|
| OH |
Occupational Health |
A medical specialty focusing on workplace injury, preemployment testing, health education, ergonomics, and therapies.
|
|
| MCO |
Managed care
organization
|
A method that employers can structure arrangements for care to injured employees. The MCO coordinates the medical aspects of workers’ compensations claims with employers, providers, or insurers and contracts with a medical network (PPO) to provide treatment.
|
| PPO |
Preferred provider
organization
|
| PP |
Preferred
provider
|
This treatment network has a group of “preferred providers” with good credentials, who understand the need for returning patients to a productive status as soon as possible.
|
|
| WC |
Workers' Compensation |
The system permitting workers to receive wage replacement and medical care for a work-related injuries and protecting employers from lawsuits for wages and injury-related costs.
|
|
| WC |
Work capacity |
Determined by the medical provider, outlines the type of work an injured employee can do. Often defined as full duty, light duty, or light duty with restrictions (should be used only when it cannot be confused with similar acronyms).
|
|
| FROI |
First report of the injury |
Generated by the employer, it gives details of the injury — date, time, place, and type of injury — and medical provider. Necessary to begin the workers’ compensation process.
|
|
| DOH |
Date of hire |
Provided by the employer, the date the employee began employment.
|
|
| FT |
Full time |
Often used in conjunction with duty descriptions; the amount an employee can work. |
| PT |
Part time |
|
|
| FD |
Full duty |
The worker has recovered sufficiently to perform all tasks required of the position.
|
|
| LD Mods |
Light duty, modifications, restrictions |
Description of work capacity an injured, employee can perform. It is defined restrictions and outlined in terms such as lifting, climbing,
twisting, and standing.
|
|
| RTW |
Return to work,
release to work
|
Physician approval for the injured person to return to some level of work.
|
|
| FCE |
Functional
capacity exam
|
Assessment of residual physical abilities and evaluation of ability to handle activities of daily living.
|
|
| IME |
Independent medical exam |
A physician exam to make a medical determination regarding causation, current physical impairment, and the need for present and future treatment. Can be considered a second medical opinion, it is generally arranged by
the insurer to confirm, rebut, or supplement medical findings offered by the injured worker's chosen physician.
|
|
| MMI |
Maximum medical improvement |
Indication that the injured worker has recovered suffficiently from injuries to a level that the MD states further treatment will not substantially change the medical outcome. |
ME
MMR |
Medical end
Maximum
medical recovery |
|
| PI |
Permanent
impairment |
Deviation from normal form or function as a result of injury, disease, or condition that has become stabilized over a sufficient period time for optimal healing to have occurred.
|
|
| MO |
Medical only |
Cases that imply the injury has not prevented the worker from working the usual job.
|
|
IND,
Indem |
Indemnity, lost time |
Money paid as wage replacement when the injured worker is determined medically unfit to work.
|
| Sources: References 6,7 |
|
