Who is Watching Your Claim Costs?

Nurse Case Managers (NCM) have become an integral part of claims management in Workers’ Compensation claims. Nurses often pay a vital role when interface with the doctor to manage medical treatment is needed for serious or complex cases. They can work as the patient’s advocate and reduce litigation by coordinating care and explaining the medical treatment and expectations to the injured worker.

But often the NCM involvement and their costs are difficult to identify without access to the NCM report and invoices. The average of $100 per hour costs are billed directly to the file under the Medical category and are not transparent due to different coding.

What is the role and responsibility of Nurse Case Managers and what results do they provide?

The currently accepted role for assignment of a Nurse Case Manager on a file is to make phone calls to the doctor’s office to confirm the current work status.  But shouldn’t this already be the responsibility of the claim’s adjuster or the claims assistant?

The main benefit of Nurse Case Management is to avoid delays in treatment caused by lack of communication between the employee, adjuster and medical provider with regards to appointment scheduling, treatment authorization and other administrative processes.  Also, the Nurse Case Manager can present the employer’s point of view to counterbalance the employee’s assertions about the availability and appropriateness of modified or alternative work during recovery.

Here are some questions to ask when evaluating the value of NMC assignments to your claims.

• What are the fees for a telephonic nurse versus a field nurse who may attend the physician appointments with the injured worker? Which is the better option for each case?

• Expected results when assigning a Nurse Case Manger? Are they achieved?

• What is the role and responsibility of the Nurse Case Manager versus the claim’s adjuster?

• Do you need a bilingual speaking NCM?

• Do you have a contract in place that defines the protocols for Nurse Case Manager referral and length of assignment?

Work with your Nurse Case Manager company and your Third-Party Administrator or Carrier to discuss accurate coding and tracking.  All claims are different, therefore, NCM assignment should be done on a case by case basis.  There should be ongoing evaluation of cost benefit, value and effectiveness of the NCM.

Here are some examples of cases that we have seen of misuse of Nurse Case Management:

• On a large client, we learned through review of the invoices that the NCM vendor was not billing in accordance with the contract and annual fees were $100,000 more than what was agreed to in the contract.   

• Client received $12,000 refund on one claim because the nurse billed for services and travel time for medical appointments that did not exist. 

• Adjuster hired a Southern CA field nurse to handle a Northern CA claim and nurse billed for travel expense to fly to Northern CA to attend medical appointments.

• NCM fees averaging $3,000/month. Employee not eligible for temporary disability benefits due to project end and no work available with the employer. We requested adjuster explain the cost savings or request NCM to close the file.  Adjuster requested NCM close her file.

ESM works with employers to ensure that Nurse Case Managers are assigned for meaningful and results driven activities. Let us help you identify the costs and manage these fees through defined protocols and accountability.