“I feel like a nurse case manager would be helpful on this file.” “I’d like to see what a nurse could do to get this moving.” “I think I might want a nurse on this one.”
Ask any adjuster, experienced or novice, why they would bring a nurse case manager on to a file, and you are likely to get a variety of responses.
Based upon managed care industry reports, the typical impact a nurse case manager can have upon claims is approximately an 18% reduction in future medical costs, a 26% lower overall claims cost and a 15% faster claims resolution.
The challenge for program managers and claims adjusters is knowing when, how and why to utilize nurse case management services. While it often makes good sense to use nurse case managers, a strategy should be in place. Excessive use may only increase claims costs while random usage can lead to lost opportunity.
You can’t manage what you don’t measure. Shouldn’t there be standard practices for referral to case management? Shouldn’t there be structure in the referral process? Mid claim utilization monitoring? Outcome measurements? Yes, yes, yes and yes.
3 top tips to consider for improved utilization of NCM services:
- Know your triggers. Bringing a nurse case manager on a file should be triggered by internal team criteria. Train the claims team on the triggers for having support on a file. These triggers can vary according to the organization. They can be injury specific, industry specific or result from social behavioral impacts identified on the initial interview.
- Know your timing. Early in and early out is the goal of a good case manager. Early intervention has been shown to be more cost effective in the long run. Claims that are likely to turn off the predictable course should have NCM support out of the gate. Train the claims team on the recognizable claim “red flags”. Early case management support can help save medical and indemnity costs.
- Know your end game. Train the claims team on the measurable markers of successful nurse case management support. National guidelines can help to predict the expected outcome. Goal markers can include: reduction in medical costs, early return to work if medically appropriate, and timely arrival at file closure (maximum medical improvement).
The opportunity for medical cost savings does exist with the appropriate use of nurse case managers! Monitor the “product” and achieve better results.