WC is published six time a year and covers the trends and topics of interest to professionals responsible for the cost-effective resolution of workers’ compensation claims.
Issue link: http://theclm.wcmagazine.epubxp.com/i/538228
TheCLM.org June | July 2015 WC 37 readily identify claims that could beneft from case management intervention. Te company also created a safety pro- gram that focused on reducing injuries, and instituted an intensive provider evaluation review that helped claims professionals and case managers better identify top performing physicians, surgeons, and physical therapists. Assess Your Current Program Where should you start in terms of assessing your current program? Actions to consider include: K Examine your current case manage- ment program. What processes and systems are you using? What criteria, if any, do you use for initiation of case management? What kind of reports and analyses are being pro- vided, and how ofen do you receive them? K Talk to your managed care vendors; know their capabilities, what they report, and how ofen they report it. K Find out how your claims' resolution compares to industry benchmarks. Are you over or under? K Where are your costliest injuries occurring—what locations, depart- ments, positions? What are your most common injuries—shoulder, back, other? Who is getting in- jured—older workers, new hires? Answering these questions will help you determine whether the problem is systemic, or confned to certain areas, and whether you need more safety education and training. K Look closely at your provider net- work—ask for data on how those providers compare to their peers. K Check to see if you have the wrong mix of providers (e.g., a lot of prima- ry care physicians, but few orthope- dists; stratify your use of providers by statistical quality metrics). K Find out who is treating your employees. Make sure you don't have the highest number of visits with your lowest-rated providers, and make sure you have a system to enable case managers to share their insights on local providers. You want case managers who can provide street-level insights into providers. K Look at both underuse and over- use of case management. If some claims professionals are going to case managers too ofen, determine if the problem is just an inexperienced per- son in need of education, or if there's a particular problem in a region. K Learn from your outliers. Te ability to look at data and reports on per- formance provides tremendous op- portunities to learn, such as whether structure, system, personnel, or a combination of factors lead to a failure in efective claims resolution. Use this information to continuously improve your program. Monitor Closely Te key to a structurally sound case management program is ensuring that someone is measuring, monitoring, and even obsessing about every element in the program. Analyzing how and when claims professionals are employing case management is a critical step. Deci- sion-making must be monitored and measured to support feedback, coaching, and improvement. However, creating sound case management programs is not exclusively about analyzing size or cost. It also is about being proactive and dynamic rela- tive to fnetuning the program to quickly respond to changing cost drivers. Tis is the only way to make sure the program continues to work as well as possible. When properly developed, imple- mented, and monitored, strong case management programs can be the keystone of successful claims resolu- tions. Tey have the potential to provide highly benefcial services, or can fall to the wayside and become cursory and inefcient. Now is the time to examine your program. Doing so will help you identify leaks, manage litigation, control costs, and guarantee efcient claims management. K Ron Skrocki is the vice presi- dent of product management and development at GENEX Services Inc. He has been a CLM Fellow since 2015 and may be reached at (610) 964-5100, ron.skrocki@ genexservices.com, genexservices.com. Creating sound case management programs is not exclusively about analyzing size or cost. It is also about being proactive and dynamic relative to fnetuning the program to quickly respond to changing cost drivers.