Case Study: Traumatic Brain Injuries

60% of workers who experience a Traumatic Brain Injury on the job, never return to work.**

 

Catastrophic claims are less than 1% of all workers’ compensation claims but account for over 20% of claims cost. Traumatic Brain Injuries are the most common and costly type accounting  for 20% of reported work-related injuries* of catastrophic claims that employers and carriers face.

Catastrophic Nurse Case Management is an effective and necessary tool for employers and carriers to manage cost and improve outcomes.

Work Comp’ Traumatic Brain Injury Employee Back to Work in 14 Months

Claimant: 45 year old male

Occupation: Hotel Maintenance

Injury: Employee sustained reported injury due to a fall from a ladder

Upon initial admission to the hospital, employee required significant sedation and intubation and placed on ventilator support.

Brain Injury Diagnosis:

Cranial CT scan revealed a non-displaced right parietal /occipital skull fracture with soft tissue swelling, bi- frontal hemorrhagic contusions, swelling in both frontal lobes, and subarachnoid hemorrhage.

A secondary cranial CT scan revealed an increased edema around the contusion in the anterior frontal and temporal lobes, mild decrease of subarachnoid hemorrhage, and no new intracranial hemorrhage. Mild decrease in the overall cerebral edema (swelling) was noted.

Recovery Timeline:

  • The claimant was placed in a drug induced coma and transferred to the ICU for multiple months.
  • Upon recovery he was transferred to a Neuro Unit and received intensive physical therapy.
  • CT brain scan findings listed improving bifrontal contusion, improved bifrontal edema, no new areas of hemorrhage, and mass effect or shift present and normal ventricles in size.
  • The claimant was transferred to an inpatient rehab facility where he received intense multidisciplinary therapies where he made significant cognitive improvements under the rehab program and transitioned to an outpatient program and was placed under the care of a neurologist.
  • After several months of intense treatment modalities and therapies, the claimant reached a maximum medical improvement with 0% impairment rating. Within 14 month of date of injury, he was released from care and able to return to work full duty..

Review Med’s Nurse was assigned to provide nurse case management for the entirety managed the case for the entirety of the claimants 14 months of recovery.

Review Med’s Catastrophic Case Management Impact:

Immediate Response:

Review Med’s Nurse Case Manager was tasked to manage the claim from the initial report of injury. She arrived at the hospital to assist employees and family through in processing. This also allowed the employer to have immediate reporting and assessment of injury prognosis.

The Nurse Case Manager complied with the carrier and employer request to visit the claimant on a daily basis in the acute phase of hospitalization.

Clarity and Understanding:

Nurse was a resource to educate the family regarding the claimant’s injury and the complex treatment recovery process.

The nurse was bilingual and functioned as a translator for the claimant and family members with providers and the carrier representative.

Claimant Advocate:

Expedited the request for a neurology consult and CT head scan.

The case manager met with various on-site case managers in order to maximize the claimant’s inpatient care.

The case manager diligently researched and located a rehab facility to adequately address the claimant’s medical and rehabilitative needs.

She kept the carriers’ in-house nurse case manager and adjuster thoroughly and timely informed regarding the employee’s status and progress.

Identified a billing error by the hospital and facilitated the correction of the error, saving the carrier unnecessary and unrelated treatment cost.

Review Med’s Nurse Case Management was instrumental to the successful positive outcome of this claim. Her involvement to function in multiple capacities and report to multiple agencies was executed attentively, effectively, and in the best interest of the claimant and carrier.

*Source References:

*  Faul M, Xu L, Wald M, Coronado V. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. For Abstract Click Here

** van Velzen, J. M., van Bennekom, C. A., Edelaar, M. J., Sluiter, J. K. & Frings-Dresen, M. H. (2009). How many people return to work after acquired brain injury?: A systematic review. Brain Injury, 23(6), 473-488 link  http://www.ncbi.nlm.nih.gov/pubmed/19484621 For Abstract Click Here

 

 

Tennessee Revises Workers’ Compensation Law, Utilization Accreditation Mandated

Tennessee approved bill revision requiring Utilization Review providers conducting UR in Tennessee to possess accreditation by approved utilization review organization committees.

This a necessary next step in the evolution of Utilization Management in Tennessee. I see this standardization of the statute to reflect the broader opportunities that employers have to provide necessary and adequate care to their injured employees.” Ken Ferrell, Vice President of Review Med

Summary of Revision

  • Public Chapter 341 (SB0105/HB0094) was signed in to law by Governor Haslam May 4, 2015.
  • The revision made minor changes to the Workers’ Compensation law, including provisions for Utilization Review Providers for Tennessee Work Comp
  • UR Providers must be accredited by either Utilization Review Accreditation Commission (URAC) or The National Committee for Quality Assurance (NCQA).
  • Providers must provide proof of accreditation July 1, 2016.

What Tennessee Employers/Insurers Need To Know

  • Nationwide only 39 companies hold URAC accreditation and 36 companies hold NCQA accreditation for UM.
  • Accreditation processes takes on average 4-6 months
  • Current UR providers should be currently accredited or actively filing their organizations application for accreditation in order to be compliant by July 1.
  • Employers/Insured should verify with current Utilization Review provider that they maintain or are seeking accreditation by either URAC or NCQA.

How This Impacts Review Med’s Current Clients

  • Review Med has been URAC accredited for Utilization Management since 2006.
  • Review Med’s URAC accreditation is current and fully satisfied until March 2018.

Review Med was one of the first workers’ compensation utilization management organizations to obtain a three year accreditation from URAC in 2006. We have maintained that high standard each time we have reapplied. Quality is at the forefront of our philosophy to always, “Do the Right Thing.” Sheryl Minyard, Director of Administrative Services, Utilization Management

What’s Next?

Both accreditation process are lengthy, rigorous and costly, some Utilization Management agents may opt not to pursue accreditation status. If your current UR provider is not accredited and will not become compliant by July 1, employers and insurers should take the necessary measures to find a new provider for their UM program.

Need expert advice? For over a decade, Review Med has maintained the URAC distinction. We are committed to excellence and have established Utilization Management solutions. We would be happy to discuss your current Utilization Management program and advise on a plan of action.

We applaud Review Med on achieving URAC Workers Compensation Utilization Management accreditation said URAC President and CEO Kylanne Green. “In today’s health care market, URAC accreditation provides a mark of distinction for organizations to demonstrate their commitment to quality health care.”

Helpful Resources

URAC Accreditation Directory

NCQA Accreditation Directory

Review Med URAC PR

For more information regarding Public Chapter 341 (SB0105/HB0094) visit WWW.TN.GOV.

 

Review Med to Host Keynote Breakfast at NWCDC 2015

Review Med will host the opening Keynote breakfast at the 24th Annual National Workers Compensation and Disability Conference, Wednesday November 11th 7:00-8:30 Am. This will be the 5th year the organization will sponsor the conferences opening event at the Mandalay Bay Hotel and Casino.  Speaker Arthur Southham M.D, EVP Health Plan Operations, Kaiser Foundation Health Plan Inc. will present Achieving Excellence in Medical Treatment following the breakfast.

“It’s an honor to be part of the 24th Annual NWCDC. Our team always looks forward to this national event and the opportunity to visit with our existing clients as well as forge new relationships with the distinguished employers and thought leaders that attend.”

The 24th Annual National Workers’ Compensation and Disability Conference, November 11-13, 2015 in Las Vegas, provides the best training available for enhancing workers’ comp, disability management and RTW programs. Thousands of professionals will gather to gain new solutions for cutting costs, effectively managing claims, reducing lost workdays, implementing an integrated disability management program, avoiding necessary lawsuits and much more.

Interested in coordinating a meeting with one of our team members during the NWCDC conference? Contact us at info@reviewmed.com.
For more conference information visit www.WCConference.com.

A Shift in the Managed Care Market

As the managed care market continues to consolidate, it’s making room for niche and smaller national companies to expand. This is a step in the right direction for these small companies who have a lot to offer in terms of client program options.

Speaking with large employers about their managed care programs gives some insight on what they are experiencing as the market choices shrink.  Large managed care companies have, in turn, large client bases, which changes the dynamic of client relations compared to that of a small company.

Bigger is Not Always Better

As a result, a common theme across these larger companies is service providers’ unwillingness to customize their programs. These companies have systems they must implement to keep their client programs in progress and make room for a constant flow of new clients. In order to keep the flow of client programs going on a large scale, there are fewer full service options available to the average client.

Program customization is rarely feasible, and client needs more likely fail to be met. 

Large managed care companies seem to devote the majority of their time, resources, and staff to their newly acquired companies.  Their programs are not being managed in a way that emphasizes client satisfaction and garners top-notch results. The flexibility or willingness to be flexible somehow gets lost in the shuffle, as do the client’s needs.

“It’s their vendors way or nothing”

One large company’s Claims Manager stated that, “It’s their vendor’s way or nothing,” and there would be no negotiation. Unique cases are processed according to a rigid program format that does not lend itself to complete client satisfaction. In today’s market, as smaller managed care companies are gaining ground, this approach seems to be failing those bigger managed care companies. Large companies are becoming increasingly hindered by their inability to remain nimble in a changing market. The ability to adapt is the key to staying afloat.

The ability to deliver a customer-driven program is lacking, but necessary, in managed care. Small, alternative managed care companies continue to expand, while large employers are making changes not to their programs, but to who delivers those programs. Only the clients, both satisfied and left unsatisfied, can judge which approach suits them.

Managed Care Services: Not All Companies Are Created Equal

We received a letter from a past client expressing her experiences with us vs a competitor and asked that we share this story:

On a fateful September evening in 2009, I was working the closing shift as a cashier at my town’s local grocery store when I suffered a tear in the external oblique muscle of my stomach as a consequence of my lifting a 50lb bag of rock salt while twisting my body to run the item across the scanner. The insurance company overseeing my worker’s compensation claim assigned me a case manager from Review Med with a medical background who was very communicative and attentive to my needs through my diagnosis, recovery and rehabilitation.

With the proper pain management, I was able to return to work two weeks later in a less physical capacity monitoring the self-checkout station. The physical therapist recommended by my case manager at Review Med helped me get back to my full range of motion six weeks after that. Because of the case manager’s correspondence with my doctors and my employer, I was able to return to my cash register eight weeks after my injury with a clean bill of health. My medical expenses set the insurance company back less than $3000.

As luck would have it, two years later it was the irresistible deal on 32 packs of Dasani water that was my undoing as I managed to tear the same muscle while running this item over the scanner. Since the store was under a new contract with the union, a different insurance company handled my claim. This time, because the insurance company assigned an adjustor with no medical training, it was an entirely contrary experience.

Due to barriers in my ability to communicate my progress and my adjustor’s inability to properly advise me, I was forced to undergo duplicate tests and examinations with multiple doctors. I saw three different doctors and none of them were in communication with my employer or my insurance company. My adjustor inexplicably referred me to a chiropractor who further injured me by performing an adjustment based on a clerical error in the chart he was provided. Since I never received a doctor’s release, Fry’s was forced to pay me not to work until I finally decided to terminate my employment six months later. A case manager with medical experience would never have allowed this to occur. The same accident resulting in the same injuries cost the second insurance company $36,000.

There are several lessons that can be learned from my experience. Chief among these is the tremendous significance of coordinated medical care for both patient and insurance company alike.

As a former claimant, I cannot underscore how little I thought about keeping costs down. My focus was solely on relieving my pain and recovering as quickly as possible so that I could get back to work. A Review Med case manager who happened to also be a nurse directed me to the best sources to make that happen. In the process, she saved the carrier nearly $33,000.

Whereas it happened to me twice in two years, one can only conclude that my worker’s compensation case was not unusual. Factoring in the potential for savings, one must conclude that nurse case managers are a valuable investment, and I wish I would have had the staff at Review Med taking care of me the second time around!

If you’re looking for managed care services, you really shouldn’t consider any other options.  Review Med is a true difference maker that creates a win-win for everyone.