Worker’s compensation patients, many times require a multidisciplinary approach to the direction of their health care recovery to ensure quick recovery and cost savings. Many times, a work injury is quite a culture shock to an employee and their family. Depending on how fast a patient recovers or what body part or parts is injured, patients may require not only an Occupational Health Provider, but also may require Orthopedics, Neurosurgeons, Psychiatric providers, Physical and Occupational Therapy, Medical Case Managers, Adjustors, Pain Management, etc.
“Health care providers (HCPs) play a central role in workers’ compensation systems. In most systems, they are involved in the legitimization of work-related injury, are required to provide information to workers’ compensation boards about the nature and extent of the injury, give recommendations about return-to-work capability and provide treatment for injury or illness” (MacEachen, Ferrier, Kosny, & Chambers, 2011, p. 582). Generally, a patient is seen by an Occupational Health provider to treat an injury such as a back strain or ankle sprain. When conservative treatment fails, a specialist referral may be needed for a consult and treat as a secondary provider or complete transfer of care. This happens commonly with back injuries being referred to Pain Management or a Neurosurgeon or other musculoskeletal conditions, such as shoulder strains or ankle sprains being referred to Orthopedics.
Case managers and adjusters work for the insurance company that insures the employer. The adjuster’s job is to manage the financial and legal details of the claim while the case manager manages the medical coordination of the file. Every state has its own set of guidelines to follow in order to stay legal competent. Case managers are generally, Registered Nurses (RN) or Licensed Practical/Vocational Nurses, who help manage the medical care of the Injured Worker (IW) and also evaluate the co-morbidities and other psychosocial factors that could impact the life of the claim.
There are many potential interrelationships and communication among different health care delivery settings for worker’s compensation patients. When effectively managing a claim, a case manager’s role is to reach out to the IW, providers, Employers (ER) and the Attorney, if applicable, to explain his/her role and to help coordinate the medical care by collecting data and devising a claim strategy. “The belief that employers, the compensation system and medical professionals focus primarily on money caused many injured workers to feel as though they were not valued, and that costs are more important than their well-being” (MacEachen, Ferrier, Kosny, & Chambers, 2011, p. 148). It is very beneficial to involve the IW, as much as possible, with preloading them with education on their injury and the anticipated medical treatment going forward. This is also great information for the adjuster and the employer. By explaining the reasoning behind medical treatment or reasons for medical treatment to be reviewed by physician advisors for denial or approval, when requested treatment falls outside of guidelines or appears medically excessive.
“Because the legislative changes are likely to impact claims management for Medicare-eligible employees, knowledge of the law is vital for nurses with responsibility for workers’ compensation claims management” (Strasser, 2010, p. 217). Injured workers who receive Medicare benefits are generally older and will have potential to be inflicted by many co-morbidities that could impact recovery and the life of the claim. “All workers’ compensation settlements for Medicare-eligible claimants that include funds for future health care expenses must include a mechanism to ensure that Medicare does not pay for the settled future health care expenditures” (Strasser, 2010, p. 218).
It is also important to remain culturally competent when dealing with patients, as well. Many cultures may not speak English and may not have the same comprehension of medical practices and may require more repetitive education, as well as, an interpreter. ”The challenge for many persons who acquire a work injury or experience changes in functioning because of a work injury is accessing information that can help to make informed decisions, or assist in understanding and planning for current and future needs” (Shaw, et al., 2008, pp. 89-90).
Some strategies in promoting health care and health care prevention for IW’s includes doing a knowledge assessment upon first contact with the IW and then to constantly reassess. Being a nurse, ADPIE becomes a repetitive process and is a nursing habit. Assessing an IW’s education level can be very helpful when proceeding forward with educating an IW. Many IW’s that were born in other countries may only have a 5th-8th grade education due to the need to work to help support the family. This can greatly impact the claim due to the fact that many IW’s may have a 5th grade reading level or lower and therefore, may not comprehend verbal instruction or written material they receive from the Adjustor or the provider. Assessing this deficit up front can help the nurse with her teaching and allow her to teach at a level more appropriate for the IW, as well as, providing more repetitive teaching and seeking feedback more frequently. Revisiting the strategy with the IW can help keep them on track and help the IW stay more compliant with care.
Unfortunately, many health care providers are not well versed in worker’s compensation process. “All HCPs acknowledge having little to no training in strategies to support effective knowledge brokering and knowledge transfer with end-users” (Shaw, et al., 2008, p. 96). There are many resources available to push a claim to closure in a timely and competent manner. Interpreters play a very important role for patients who are non-English speaking and can assist greatly when an IW is seeing a provider. When a claim in not moving forward in a timely manner or treatment is looking like it has stalled, a Task Nurse can be assigned to attend an IW’s appointment to discuss the treatment plan with the provider, assess the IW upon arrival and offer recommendations according to past experience with the same types of injuries. While Task Nurses cannot direct care, they can offer suggestions for care going forward to allow the IW to actively treat in a competent and timely fashion. Some barriers to worker’s compensation claims may include attorneys who may prohibit the MCM and CCM from speaking with the IW and may change providers multiple times to stall treatment, at the potential detriment of the IW. Jurisdiction does play an important role in how a claim proceeds. In Ex parte states, MCM’s cannot contact providers without Attorney permission or even the Attorney on the other line.
A worker’s compensation file can become complicated and very involved if not managed appropriately from the beginning. “Currently, there are large gaps and inequities in how information is being used in the RTW (Return to Work) process and yet there is great opportunity for collaboration to improve the process” (Shaw, et al., 2008, p. 100). Health care providers need to be more thorough up front when identifying, not only the details of the injury, but also any non-industrial injuries or health care issues that may come into play to impact the claim later. “Secondary problems eventually became more serious or prevented a return to work, medical records were not available to demonstrate to the compensation board that the problem was related to the original injury” (MacEachen, Ferrier, Kosny, & Chambers, 2011, p. 586). Barriers, lack of proper care coordination, and jurisdictions can impact successful closure of a file. Placing a Medical Case Manager on the file to coordinate appropriate claim strategy with adjustors, providers, injured workers and attorneys, is both aggressive and culturally and medically competent for timely and appropriate closure.
MacEachen, E., Ferrier, S., Kosny, A., & Chambers, L. (2011, April). The Role of Health Care Providers in Long Term and Complicated Workers’ Compensation Claims. Journal of Occupational Rehabilitation, 582-590.
Shaw, L., McDermid, J., Kothari, A., Lindsay, R., Brake, P., Page, P., . . . Knott, M. (2008). Knowledge brokering with injured workers: Perspectives of Injured Worker Groups and Health Care Professionals. Work , 89-101.
Strasser, P. B. (2010). Workers’ Compensation Management—Changes in Medicare Regulations. AAOHN JOuRNAl, 5, 217-219.