At a time where medical benefits account for more than 60% of workers’ compensation claims costs across many jurisdictions, effective managed care partnerships have become more critical than ever. These partnerships not only significantly impact the quality and cost-effectiveness of services for injured employees but also introduce new efficiencies into the claims management process, alleviating the burden on claims payers.
While our industry is not without challenges, the two concerns I hear often are around the need to control costs and the facilitation of a quick and safe return to work (RTW) for employees.
Cost containment
In today’s business landscape, cost control is a top priority for every organization. While managing workers’ compensation costs can be complex, it is achievable. At Careworks, we tackle this task daily — pushing the boundaries of cost containment through innovative advancements to refine our solutions, models and processes. By doing so, we’re able to identify the most effective clinical actions to expedite injured employees’ recovery while saving costs for our clients.
Through network management and medical bill review, we can help payers contain costs. We believe effective network coverage isn’t just about the size of a network – it’s also about customization and harnessing the experience of our network team to create the most effective network mosaic. This includes state-level custom mosaics that provide clients access to the best possible provider networks. Our experience in building and maintaining a national network of providers specifically for workers’ compensation patient care means injured employees get to the right provider at the right time and clients pay the right fees.
Within our ancillary care network, we have enhanced our product catalog and formulary as well as improved efficiencies through direct integration with network providers. These enhancements enrich the experience for injured employees by reducing lag time and ensuring the most appropriate equipment and services are provided at the best cost-to-value ratio. Within our medical bill review solution, we have refined the review process through enhanced proprietary algorithms designed to efficiently detect errors and inconsistencies, thereby boosting accuracy, leading to significant cost reductions and financial benefits for payers.
Clinical intervention
When an employee suffers an injury at work, they often grapple with pain, frustration, uncertainty and anxiety about their recovery and their ability to return to work. Early engagement with a clinician helps to ease concerns and ensure they receive the necessary support and resources to guide them through their recovery and return to work.
We provide an end-to-end clinical model, with our nurses involved from the time of injury — guiding employees towards the most suitable and cost-effective care. Within the first two days, we follow up with the injured employee to clinically assess their situation, and if appropriate, a telephonic nurse case manager is engaged. Our nurse works alongside the claims examiners to identify barriers that may delay recovery and implement specific strategies to mitigate costs and promote safe, appropriate care and recovery.
For claims involving surgery, which are often costlier and lengthier, a specialized surgery nurse engages the injured employee in their recovery process using a pre-habilitation/rehabilitation clinical model. This proactive approach includes education, home preparation, and lessons on physical strength and well-being, has been proven to reduce complications, improve recovery times and facilitates a safe return to work.
In all cases, we empower our nurses to collaborate, investigate, and apply clinical judgment and advocacy to every case. I recall a case where an injured employee had an accident involving her shoulder which eventually led to a surgical repair. The employee mentioned chest and shoulder pain within a few days of surgery, which the provider originally dismissed as normal post-surgical pain. Our nurse, digging deeper, suspected otherwise and advised the employee to visit the emergency room. The outcome was life-saving: the ER identified that the employee had pulmonary emboli which could have been fatal without immediate medical intervention.
Within our clinical intervention model, we are developing ways to use advanced claims guidance technology that uses artificial intelligence (AI) and machine learning to further improve our model in identifying the most effective level of nurse intervention as early as possible in the life of the claim. This will not only enhance claim outcomes, but it will also provide an enhanced experience for the injured employee.
Moving forward
I believe that work is therapeutic and integral to the human condition. Facilitating an injured employee’s return to work is not merely about resuming productivity. It’s a vital part of their recovery process, providing them with a sense of purpose and normalcy that can significantly enhance their overall well-being. At Careworks, we remain committed to identifying RTW barriers early on and collaborating with specialists to devise effective plans that improve employees’ medical conditions, enabling them to return to work safely.
If you’ve read my previous blog, there is a common thread — the importance of connections and choices — to people, businesses, colleagues and beyond. As we face various challenges in our industry, those connections are crucial, as are strong business choices. That’s why we’re focused on strengthening client connections – to understand their needs even better, collaborate more effectively, and develop new solutions and choices that address their unique challenges. We are well into 2024. As expected, it’s a busy year – so much has already happened. But with our renewed commitment to serving the needs of the managed care industry and with a commitment to staying connected, we’ll address the challenges of this and future years together.