Rocks That Roll Downhill

It's Friday afternoon before a three-day holiday weekend, and your injured employee is being discharged from the hospital. He receives a prescription—either electronic or paper, as I've seen it both ways—upon discharge. "Meds to beds" programs are rare, so he or his family must go to the pharmacy to pick up the medications. The pharmacy informs them that the prescriptions need approval from the insurance company. The nurse case manager (NCM) points out that he has a workers' compensation card, but the pharmacy insists that two of the medications still require insurance approval.

By now, it's 6 p.m. on Friday before the holiday weekend. The insurance company is closed, the claims adjuster is unavailable, and the medications won't be approved in time. So, what’s the solution? The injured employee could pay out of pocket, but he has no money. He could ask his sister-in-law for help, but they haven’t spoken since he borrowed her car last year and damaged the alignment by hitting a curb. Still, the advice is to ask her for the money and keep the receipt for reimbursement—though we all know how long that process can drag out.

As an experienced work comp case manager, I can navigate this mess, but what about a new NCM? This scenario isn’t covered in basic training. I’ve seen injured employees go home post-surgery without approved meds and end up in the ER within 24 hours, driving up costs due to these hiccups and gaps. It’s just one example of how processes impact other processes. Think back to your early learning about computer programming with "if, then" scenarios: if you program "this," then "that" happens. The process of Mr. Smith landing in the ER stems from an internal process where a medication triggers a red flag for approval. The NCM, stuck outside that process, has their hands tied. It’s like a rock rolling downhill, the Case Manager is always expected to catch it and stop it from going too far.

How many rolling rocks have you caught lately?