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					The Day of Injury Study 2005
       Final Report

            Day of Injury

      “Controlling the workers’
      comp line of scrimmage”

                             S Y S T E M S
                            rtw / di sabi li ty management
                            CCI Chandler Consulting Inc.
                          The Day of Injury Study 2005
                                 Final Report

The by-line of this study is: ―Seize the moment and capture early opportunities to
control worker’s compensation costs.‖ This study is a forensic analysis of several
guiding principles of an employer’s worker’s compensation program. These are:

                    Timely reporting of claims
                    Employee’s access to quality medical treatment
                    Early return to work

The scope of work of this study is to identify best practices and measure the
results of an integrated employer response on the day of injury. The findings will
evidence that the day of injury is the most critical stage of a worker’s
compensation claim. The nature, duration, cost and eventual outcome of a claim
can be largely shaped and controlled by the employer’s response on the day of

What most employers fail to recognize is the window of opportunity to initiate and
control worker’s compensation through their efforts in injury reporting, access to
medical treatment and a systematic return to work process. In order to best
illustrate this point, a popular sports analogy will be used. In the game of
football, the team that controls the line of scrimmage controls the game and
rarely loses. In worker’s compensation, the day of injury equals the line of
scrimmage. In this scenario, an injury report is an offensive play. A play stopped
for no gain is a ―report only‖ or first aid. A play resulting in a short gain is a
―medical only‖ or medical only-restricted duty claim. The object of the worker’s
compensation game is to limit indemnity claims (long gains) and keep the score
down (lower costs). The employer must have a good defensive strategy. How
do you limit incidents to ―no gains‖ or ―short gains‖? How do you fill the gaps in
the line of scrimmage to prevent ―long gainers‖? As this discussion illustrates, a
good defensive strategy requires a dynamic process with a concerted team-like
effort from each of the key positions: supervisor, human resources, medical
provider, and claims management. If these players underachieve or miss their
assignments, the results are costly and penalties in the form of litigated claims
can occur. The employer’s best defense is to focus on controlling the claim at
the line of scrimmage (day of injury).

Study Backdrop
The study was conducted at Schools Insurance Authority (SIA), located in
Sacramento, CA. SIA is a pool of thirty-four (34) school districts located in
several northern California counties. SIA is a public entity, joint powers authority
which administers a self funded/self administered workers compensation
program for 19,500 employees with an annual payroll of 550M.

The California worker’s compensation system has maintained a top five ranking
in all the wrong categories: frequency, duration, and cost of claims. With recent
comp reform, 2003-2004, the CA comp system is heading in the right direction
for reducing system costs. The principles derived from the study have a
universal application to all workers’ compensation jurisdictions.

Study Report
This report will be divided into four sections:

              Section 1 – Injury Reporting
              Section 2 – Partnering with Medical Providers
              Section 3 – Early Return to Work
              Section 4 – Final Conclusions

                        Section 1-Injury Reporting

                 Injury Reporting- Notification

Initial Injury Report
What is the most effective procedure/protocol for injury reporting? Why?
There are numerous variations of timely reporting: use of a paperwork process
via inter-office mail, day of injury fax, vendor-based call centers, and on-line
internet/intranet technology. In this study we will examine what is critical to the
injury reporting process and how the employer’s action can shape the nature,
duration and cost of the claim.

The Cost of Late Reporting
A recent study by The Hartford of 53,000 permanent partial and temporary
disability claims reported the following:
    Claims with lag times between 7-14 days were 18% more expensive than
        claims filed in 1-6 days
    Claims with lag times between 15-28 days were 30% more expensive.
    Claims with lag time >29 days were 45% more expensive.
The Hartford study clearly underscores that late reporting has financial
implications for claims.1

                          COST OF LATE REPORTING
                                    The Hartford Study, 2000




                     Increased Claim
                     3-D Column 1      1-2 weeks       3-4 weeks   >4 weeks

Reporting Methods
How does an employer’s methodology affect the injury/illness incident? What
training is provided to supervisors on injury reporting? What are the factors that
can influence the outcome of an incident report? There are various methods of
injury reporting. The prevailing internet culture supports a ―high tech/low touch‖
approach. Many employers utilize web-based reporting, fax reports, and insurer
call centers, while many employers rely on the traditional paper form process
completed by the supervisor and employee. The study will examine various
process benchmarks to rate various methods of injury reporting. The following
section overviews the most utilized methods of injury reporting.

Paperwork Forms
This is a widely used, inexpensive method of recording injury/illness claims. The
downside issues are numerous: poor quality of information, often incomplete,
and, depending on an employer’s internal processes can lead to lengthy delays
in reporting (lag time) and lost reports of incidents/claims altogether. The
―garbage in/garbage out‖ scenario can be very costly in comp. In the absence of
a well-managed injury reporting process, this method can create unnecessary
comp costs. Even if the process is well managed, how good is the information
that is being completed by numerous untrained parties, supervisors, secretaries,
and employees?

Faxed Report
The clear advantage of a fax over a paperwork process is the speed of
information dissemination. Many employers utilize internal faxed reports to alert
the organization to an incident/claim, thereby engaging medical treatment and
return to work processes. Quick dissemination of information is one benchmark
of success. The quality of information received and the response to that
information remain issues at many organizations.

Internet/Intranet Reporting
This method scores big on ease of use, uniformity, and timely dissemination of
information. Compliance can be an issue; some organizations offer options,
internet, form etc. The lack of a standardized process can lead to late reporting.
The prevailing downside of internet reporting is the quality of information received
due to multiple users and the ―low touch‖ aspect when dealing with the injured
employee. This will be explored in the reporting benchmarks section under
Employee Satisfaction.

Call Centers
There are several variations of call centers, some staffed 24/7, some staffed
during normal business hours, and some centers are telephonic reporting to a
recorded menu-driven process. Those with ―live operators‖ and ―injured
employee friendly‖ processes score higher. The keys to success lie in
addressing the employee’s concern surrounding the incident/injury and providing
needed information. Information delivered at critical moments following an
incident go a long way in alleviating the employee’s concerns.

RN ―First Call‖
This method utilizes a nurse to take the initial injury report directly from the
employee/supervisor immediately following the incident. SIA has a dedicated
toll-free line directly to an ―intake‖ RN. Other vendor- based nurse staffed call
centers, Company Nurse™ and Medcor™ offer similar services. At SIA, the
nurse is contacted immediately after the employee reports the incident to their
supervisor. The nurse completes all required reporting forms from the intake
process, thus alleviating the need for supervisor and employee completion of
forms. Alleviating forms completion at the site scored big for ―ease of use‖ by
supervisors and employees. The quality of information requested/recorded by
the nurse provides the claims management team with supervisor data
surrounding the incident. This significantly impacts the claims examiner in the
compensability decision process. The most significant impact of the nurse intake
is the medical triage component. This offers the opportunity to keep the incident
classified as a ―Report Only‖ or ―First Aid‖ claim. The SIA telephonic nurse triage
process was extremely effective. Approximately 40% of all injury reports (calls)
did not result in the employee decision to seek medical treatment. The intake
interaction promoted positive communication in an often adversarial comp
process. Detailed information about the impact of the nurse ―First Call‖ process
is included under ―SIA Findings‖ in this section of the report.

Injury Reporting Benchmarks
The following benchmarks were selected to evaluate the overall scores of the
various reporting methods listed above:

 Ease of Use: The rationale is that an easy to use, access-friendly process will
  result in greater compliance in day of injury reporting.

 Quality of Information: A factual, sequential, detailed incident report serves all
  the stakeholders immediately. A considerable amount of effort on the part of
  claims management often occurs in chasing down incomplete reports to
  determine the facts of an incident. With accurate initial reporting there are less
  claims investigations, resulting in expedited claims decisions. It is interesting to
  do a case review of problem comp cases and notice the ―missed opportunities‖
  to control the claim due to poor, incomplete injury reporting.

 Timely Dissemination: This benchmark applies to all primary stakeholders:
  employee, supervisor, Risk/HR, claims management, and medical provider.
  The most effective comp programs promote an integrated process for
  successful medical treatment, return to work, and claim resolution. It all starts
  with accessing information immediately.

 Employee Satisfaction: While comp is a ―no-fault‖ system, it is complex,
 adversarial, legalistic, and easily manipulated in many states including
 California. The ―system trappings‖ with comp are numerous: terse, legalistic
 communication; claims investigations; delayed decisions; delayed medical
 treatment; injury/pain. These ―trappings‖ create an atmosphere of uncertainty
 for the injured employee. In a 1997 study, A Study of Injured Workers and
 Their Experiences with the Workers’ Compensation System, Communication,
 Concern & Caring, INTRACORP reported that employers are in the fortunate
 position of being able to control or influence most of the factors that contribute
 to injured worker’s satisfaction levels.2 The report goes on to point out that
 employers that communicate with their employees receive better overall comp
 claim outcomes i.e. faster return to work, less litigation. It all starts on the day
 of injury. What methods promote positive communication in a fair, impartial
 process? The employee’s satisfaction level often determines the course of the
 claim. The issues faced by an employee in an on the job injury are numerous as
 reported by INTRACORP in the 1997 report. These are: anxiety/uneasiness
 about the injury/comp system, medical treatment decisions, and fear of job
 loss.3 SIA uses an efficient injury reporting process combined with
 straightforward information and a dose of TLC ―high touch‖ to address
 employee concerns. The SIA findings offer some surprises on how simple
 measures do influence outcomes.

 Claims Process Integration: Which methods provide easy integration with the
  claims process and provide quality data to support the legal/medical aspects of
  the claim? How quickly is the claim examiner notified? At SIA, the process is
  integrated with the nurse intake and happens within minutes of the call.

 Early Return to Work Integration: The goal at SIA is to prevent a lost
  time/indemnity claim if at all possible by immediately engaging a modified duty
  return to work process. In California and many states, indemnity claims kick in
  after three (3) calendar days of time off work.

 So in order to avoid a lost time claim for an employee who was injured on
 Friday, he/she must be back to work on Tuesday. The key elements are having
 pre-identified return to work options and being able to access physician work
 status information on the day of injury/treatment.

 Medical Triage Process: This benchmark alone could qualify as the single most
  important process that SIA implemented. The nurse-employee exchange of
  information had a profound effect in the filing of a worker’s compensation claim.
  The medical triage was so effective that it is easy to speculate that 25+% of the
  incident reports would have been claims if not for the medical expertise of the
  nurse. It also set the foundation of the employee’s relationship with the comp
  process and their resulting satisfaction level.

                              Injury Reporting Report Card

                                       Paperwork/   Fax    Internet     Call           RN
                                         Form                          Center          First

Ease of Use                                X         X       XX         XXX            XXX

Quality of Information                     X         X        X          XX            XXX

Timely Dissemination                       X        XX       XX         XXX            XXX

Employee Satisfaction                      X         X        X          XX            XXX

Claims Integration                         X         X       XX         XXX            XXX

RTW Integration                            X        XX       XX          XX            XXX

Medical Triage                                                                         XXX

       X = least effective
       XX = moderately effective
       XXX = most effective

And. . . . . . the winner is: Nurse ―First-Call‖ injury reporting process. The ―high
tech/high touch approach produced a noticeable decline in claims on the day of
injury. The results were surprising, even early on, when the nurse self-care
numbers were piling up. The feedback from the districts and the employees on
the injuring reporting process was very positive at the outset.

A major component of the Day of Injury Study is to examine the data of the
telephonic nurse injury reporting/triage since July 1, 2000. The following
tables/charts provide the baseline support for the study.

     Telephonic Nurse Reporting /Structured Return-to-Work
                           Implemented July 1, 2000
             Data valued for identical year-end period of 7/1 – 6/30

                                          2001          2002         2003            2004          2005
    Total Incidents Reported              1589          1577         1526            1500          1425
    Report Only/RN Self-Care              594            562          662            600           580
    New Claims                            995           1015          864            908           845
    Indemnity (% Claims)             184 (18%)      174 (17%)     210 (24%)        254 (28%)     161 (19%)
    Medical Only (% Claims)          811 (82%)      841 (83%)     654 (76%)        654 (72%)     681 (81%)
    Medical Only Restricted Duty          303            215          235            231           225

                   W.C. Incidents & Claims / Types
       1589 1577             Comparison

                                     9951015 908
                                              845                    811 841
                      594 662                                               654
                         562 600                                            654    681

                                                           254                        303 235
                                                         210                                231 225
                                                    184174     161

       Incidents          RO/RN       Claims        Indemnity            MO              MO-RD
                           3-D Column 1    2001   2002     2003   2004      2005

INCIDENTS = All telephonic reports
RO/RN= Calls were either a Report Only or a Nurse Self-care, i.e. not referred to
medical treatment, no claim filed.
CLAIMS= New claims during year.
MO= Medical Only
MO-RD= Medical Only-Restricted Duty; claims employee unable to RTW full duty
but returned to modified/restricted duty within 3 calendar days to prevent an
indemnity claim.

   1. The injury report line promotes the reporting of all incidents. All incidents
      are recorded in the claims database. Should an injured employee later
      require medical treatment, the information is easily accessed to initiate the
      claims process and protect the employee’s right to file a claim.

   2. The lag time between the employee’s notification to their supervisor and
      the report of injury filed with a call to the nurse was usually the same day.
      Overall lag time for the five year period was less than 1.5 days.

   3. The nurse triage process is highly effective in assisting the employee in
      the decision to seek medical treatment on the day of injury:
          39.36% of all calls (incident reports) over five (5) years did not result
           in medical treatment; therefore, no claim was filed. 5 year totals:
           7,617 incidents; 2,998 RO/Nurse Self-care cases

           94% of all RO/Nurse Self-care calls remained in a ―no claim/no
            medical treatment‖ status at 90-days post call. This is an unexpected
            finding. The assumption was that a much higher percentage of
            calls/incidents would result in medical only or indemnity claims. This
            finding also supports the overall satisfaction of the employee with the
            nurse triage services (self-care advice) given to the employee on the
            day of injury.

                       RN First Call Results
                During the last 3 years, 1826 injury reports
                 were handled as RN Self-care.
                94 % of those incidents remained as RN
                 Self-care (no further medical treatment) after
                 90 days.
                Top three nature of injury categories were:
                 strain/sprain, bruise/contusion, & laceration.

   4. The RN injury report process promotes positive communication with
      employees. The overwhelming response from employees has been very
      positive. During the first year of the EIN/SRTW Program, claims litigation
      rates dropped 67% and have remained well below CA litigate rates for the
      past five years. SIA average claim litigation rate for the past 5 years is 7%
      of all claims. The CA statewide average is approximately 20% of all
      claims. After reviewing litigation rates and interviewing SIA staff, the
      employee satisfaction survey that was planned during the study was
      tabled. The CA comp reform in 2003-2005 has created a hotbed of
      political activity with plaintiff attorneys, medical providers and unions. SIA
      will consider implementing an employee survey when the comp system in
      CA further stabilizes.

   5. The RN injury report process integrated well with the early intervention
      return to work program in the twenty-eight (28) school districts. The
      results over the five years demonstrates that 26% of claims were
      classified in a medical only/restricted duty status.       These injured
      employees had medical work restrictions that precluded a full duty return
      to work. In California, if the employee has not returned to work within 3
      calendar days, the claim would be classified as indemnity and the
      employee eligible for wage replacement payments. In a 90-day follow-up
      review of these MO-RD claims during FY-03, FY-04, and FY-05, 92% of
      these claims remained in a medical only status. Again, there was an
      expectation of a higher rate of erosion into indemnity claim status at the
      start of the study.

   6. The nurse injury intake process facilitates speedy claims decisions. In
      California, since the 2004 reform, employees have access to medical
      treatment up to $10,000 while the claim is in a pending status, awaiting a
      compensability decision. The quality of information exchanged between
      the employee and the intake nurse promotes an expedited claims decision
      process. If red flags are identified during the telephonic intake process,
      the claims examiner can immediately initiate the medical/legal
      steps/evaluations to accelerate the claims decision process.


The study also examined two similar programs in school districts in Northern
California. Both organizations presented some differences in program design
and resources. Sacramento City Unified School District (SCUSD) is a large
urban, inter-city district employing approximately 5,000 employees. SCUSD
implemented a similar program utilizing a nurse injury report line and an early
intervention return to work program. Their program was implemented in 2002.
The following program evaluation encompasses the first two years.

                              Sacramento City USD
               Early Intervention Nurse / Structured Return-to-Work Program
                    Implemented December, 2002, Two Year Evaluation

                                     2002              2003                2004               Results        Results
                                                                                             ‘02 vs. ‘03    ‘02 vs. ‗04
Claims                                732              467                 390            36%Decrease      40% Decrease
Indemnity (% Claims)               261 (36%)         160 (34%)          125 (32%)         39%Decrease      52% Decrease
Medical Only (% Claims)            471 (64%)         307 (66%)          265 (68%)         35%Decrease      44% Decrease
Report Only                           33               201                 213            609%Increase     645%Increase
Litigated Claims                      43                30                  13            30%Decrease      70% Decrease
Total Incurred                     2,676,144*        1,657,904          2,134,500**       38% Decrease     20% Decrease

Indemnity Paid                      314,450          245,022            225,106**         22% Decrease     28% Decrease

Medical Paid                        479,357          454,424             457,804          5% Decrease      4% Decrease
                                                 *Backed out one claim incurred in excess of 1.5M
                                                ** Indemnity weekly benefits increased 17% in 2004

                                      W.C. Claims Breakdown


                       467                              471

                                                              307 265
                                           160 125

                                                                               33                   43 30 13
                   Claims             Indemnity             Medical                  FA               Legal

                                                     2002     2003      2004

Redwood Empire Schools Insurance Group (RESIG) is similar to SIA. RESIG
represents forty-five (45) school districts in Sonoma County (Northern California)
with approximately 13,500 employees. RESIG implemented a nurse injury report
process and early intervention return to work program in 2003. Their results
following the first year of operation show:

         Redwood Empire Schools Insurance Group
                 EIN /Structured Return-to-Work Program
                        Implemented January 1, 2004
            Data valued for identical year-end period of 1/1 – 12/31

                                     2002           2003     2004         Results,
                                                                         ‘03 vs. ‘04
         New Claims                  618            493      503       01% Increase
         Indemnity (% Claims)      216 (35%)   201 (41%)   141 (28%)   30% Decrease
         Medical Only (% Claims)   402 (65%)   292 (59%)   362 (72%)   24% Increase
         Total Incurred            4,339,999   3,241,978   1,878,240   42% Decrease
         Indemnity Paid            554,119      568,145    448,052
                                                                       35% Decrease*

         Medical Paid              256,899      196,750    156,040     21% Decrease
         Total Paid                811,018      764,895    604,092     20% Decrease
                          *Adjusted for 17% benefit increase in 2004

Redwood Empire Schools Insurance Group, Windsor
First Year Evaluation, 2004 vs. 2003
     Total Incurred costs decreased 42%.
     Total Indemnity paid costs decreased 35%.
     871 incidents reported, 503 claims filed, 42% of all incidents did not result
       in opening a claim.
     148 claims were placed in modified duty within the first 3 days to avoid an
       indemnity lost time claim.

City of Little Rock.
In 2001 the City incorporated into their comp system the Company Nurse™
program, similar in operation to the nurse injury intake process at SIA. According
to the City, they experienced a 20+ day reporting lag time. The largest city in
Arkansas was using 3 different documents to report a claim. This procedure led
to a major inefficiency in proper reporting protocol. The excessive lag time was a
large contributor to rising comp costs. After the Company Nurse injury
management program was implemented, reporting lag time decreased from 20+
days to 2!4

The immediate notification from Company Nurse allowed early intervention in the
medical treatment and a quick follow up to the provider when further treatment
was required. The City was able to respond immediately with appropriate
modified duty assignments when the employee could not resume full duty. The
results, identified in the chart below, reflect substantial cost savings since
implementation in 2001.

          Year     Reported    Lost Time –    Lost Time -   Total Cost
                    Claims     Hours          Cost
          1998       382          9,995       $ 158,780     $480,249
          1999       296           9,145      $ 143,274     $544,218
          2000       334          12,066      $ 173,690     $843,011
          2001        331         3,836       $ 66,714      $473,070
          2002       377          4,835       $ 76,829      $523,092
          2003       339          2,240       $ 39,687      $344,011
          2004        318          1,429      $ 20,333      $298,478

The City of Little Rock experienced a 44% reduction their Total Cost from 2000 to
2001. This downward trend continued through 2004.

 Company Nurse™
Company Nurse™ provides nurse triage injury report services to employers
throughout the U.S. The firm reports a 34% non-referred rate. In their study of
11,775 calls, the nurse triage service handled 32% of the calls as a Nurse Self-
care. These calls did not require further medical treatment, hence no claim filed.5

Injury Reporting Conclusions

According to the aforementioned INTRACORP, 1997 report,

―Several surprisingly simple employer initiatives can significantly affect workers’
comp program outcomes. According to the study, prior communication and post-
injury demonstrations of concern and caring drove higher levels of injured worker
satisfaction, reduced time lost from work and reduced attorney involvement--all
factors that contribute to lower program costs. The good news is that with a
focused strategy, employers can easily address these factors and improve their
program results.‖6

                  It’s All About Xs & Os

Schools Insurance Authority did exactly as the ―Coach‖ suggests: they re-thought
their core processes beginning with injury reporting. The use of an occupational
nurse to take the employee’s initial injury call paid huge dividends. This is an
effective defensive strategy for controlling the line of scrimmage, day of injury.

The keys to a successful injury reporting process as modeled by SIA are:

      Keep it simple, have a single point of contact to keep the process uniform.
      Staff the injury reporting process with an experienced triage nurse, either
       in-house or using a contracted service. The quality of information derived
       from this process greatly impacted the claims management function and
       builds a positive relationship with the employee.
      Make it easy to use for employee and supervisor; a phone call is efficient
       and personal especially when talking to a medical professional.
      Immediately integrate the injury reporting process with access to qualified
       medical care. Employees that receive medical treatment on the day of
       injury have much higher satisfaction levels.
      Set an expectation of early return to work with prior targeted
       communications and reinforce it on day of injury.

Ask yourself, what is the financial impact of 25-40% of the reported incidents not
becoming a workers’ comp claim? There is a significant economic opportunity to
be explored with a Nurse ―First Call‖ injury reporting process. SIA stands by it.

                  Section 2- Partnering With the Medical Providers

Re-thinking the Proposition

Under the context of a day of injury early intervention initiative, communication
with the medical provider is essential. What actions can the employer utilize to
develop better working relationships with local medical providers? One goal of
the study was to provide some specific strategies and the necessary tools for
employers to build better relationships with their medical providers.

A resource manual of best practices was developed in conjunction with the study.
This is available from PERI. This manual offers additional training, process tools,
targeted communications, checklists and forms. These documents will be
discussed and referenced (by italicized notation) in this report.

In a recent Integrated Benefits Institute (IBI) Physician Survey, Physicians
Managing Disability Opportunities and Constraints, April 2002, reported:

        ―The biggest obstacle to physician involvement in RTW is that they seldom
are asked. Eight physicians in ten are contacted infrequently or never by
employers regarding RTW. Further, though physicians will release workers to
transitional work, more than half won’t do so unless the employer offers
appropriate work in a manner that requires no additional effort by the physician or
physician’s staff. Finally, more than half the physicians ask workers how much
time off they want and one-third ask how many weeks of disability are available.
Such questions can create expectations for the workers and set the stage for
disability determinations based on other than medical grounds.‖
        ―The two resources most requested by physicians to manage disability
should be the ―sleeves from the vests‖ of employers seeking early RTW: 1)
detailed job descriptions and/or offers of transitional work by employers during
recovery (72% of physicians) and 2) employers willingness to follow the
physician’s work restrictions in transitional work (64%). Other resources
commonly needed include the ability to refer to medical specialists better able to
treat the disability (58%). Almost half say they welcome training in RTW and
transitional work placement during healing.‖7

The critical components derived from the IBI Survey are:
   1) Willingness by the employer to open communication channels with the
   2) Detailed job descriptions of modified and regular work assignments,
   3) A commitment to work together in a collaborative effort for ongoing
       education and problem-solving.

A related study, (INTRACORP, 1997), reports 20% of employers gave their
employees recommendations for doctors or hospitals to visit. In the survey, 75%
of the injured workers viewed recommendations as positive or neutral. When the
employers provided medical provider recommendations, more than 90% of the
workers followed them.8

Today’s organizational environment, with its focus on teamwork, lends support to
innovative strategies for partnering. In the field of disability management, one
such potential partnership that deserves full consideration is that which can be
established between the employer and local medical providers. And it would
seem to be a simple arrangement to initiate, right? All that needs to be done is to
start communicating with the physicians. But immediately, concerns arise for the
RTW Coordinator, who may voice anxieties in the form of questions such as
―Who, me? How? When? Are you sure I can?‖ A mystique may surround the
whole area of communicating with the physician. It’s a medical situation, a
privileged communication that the employer does not have a right to access.
Today more than ever, great confusion surrounds the question of what
regulations actually demand, as far as the protection of individual rights &
protected health information. Many of the stakeholders in the disability
management process are unclear as to the advisability of sharing medically
related information between physician, patient and employer. What information
can be provided to the employer? The employer has a right to request
information pertinent to the employee’s ability to perform work, whether it be full
or modified duty in the context of a work-related injury. Most occupational
medicine providers that offer initial medical treatment will provide a report
outlining the employee’s work status. We expect the physician to provide the
conditions (work restrictions) under which the employee can safely return to work
if they are not released to full duty.
Occupational physicians and many other medical providers understand the
significance of the employer’s role, both in financial terms, and in the medical
recovery process. Acceptance of the merits of early intervention/return-to-work is
very widespread among members of the medical community. Often, employers
claim that the greatest obstacle standing in the way of the employer’s ability to
control comp is the physician, demanding that their injured patients remain off
work. This, however, is a view that needs to be reshaped.

Most Employers Have Routinely Avoided an Active Role in the Medical
   Community — Why?
Some state workers’ compensation guidelines allow the employee to choose the
physician. Many employers in these jurisdictions are in a ―hands-off‖ posture and
refrain from assisting on the selection of providers. There is often no attempt to
help channel employees to qualified occupational medical providers. In many
states, the employer has a right to select a group of physicians to provide
treatment. What criteria drive their choice of physicians? The study will offer
some guidelines below.

The Supervisor‘s Lack of Support for Anything Short of Full Duty
The whole-person-or-no-person paradigm permeates the supervisor’s thinking,
even in organizations with semi-operational return-to-work efforts. These
attitudes must be challenged and the organization needs to educate supervisors
about basic disability management concepts and the vital role of return-to-work

Success Strategies — Medical Provider Survey

1. Choice of Physician
From the outset, the study emphasized a collaborative effort in the disability
management process. The first task is to survey medical treatment options in the
local community. Start with a list of physicians used by employees in the past.
Mark the name of each physician with a plus (+) or a minus sign (–), if you can
determine whether they supported the return-to-work process, or were overly
protective of their patient and inhibited early return to work. Next, review the
Yellow Pages for occupational medicine or industrial medical providers. Contact
other large employers in your local communities to determine if they have return-
to-work programs, and which physicians have been supportive of their efforts.

2. Telephone Survey
Using the Telephone Survey Sheet provided in the resource manual, contact
several of the providers. The contact person is generally the office manager or
administrator. Complete the survey sheet, obtaining general information about
services, hours, physicians, and references. Set up appointments to visit several
providers to review their office settings and services, and complete the on-site
survey portion of the medical survey form.

The goal is to establish working relationships and open up lines of
communication. Let the providers know that the organizations can assist the
physician in the return-to-work process. Provide the physicians with information
about the organization’s return-to-work program. Discuss the providers’
preferences as to communicating with employers. Do they prefer a call before an
employee is seen? How do they provide information following the initial
treatment? Be sensitive to the concerns expressed by medical providers,
particularly as they pertain to the additional demands on the physician as
required by the state workers compensation program.

Many medical providers view workers’ comp as a complicated process. The
employer and their claims management team can really assist with physician/
provider education. Ask the provider their concerns about the system, i.e. timely
authorization for treatment, right to refer to specialists care and billing concerns.
Discuss the preferred communication methods, phone, fax, or email. Ask the
physician if they are open to phone conferences to discuss a problem case?
Most physicians welcome the employer’s perspective on an issue. Other
physician concerns include the physician’s liability surrounding the employee’s
release to modified work. Physicians may be reluctant to release patients back
to work with work restrictions if the employer has not established specific
parameters in their return-to-work program. The physician’s concern is whether
work restrictions will be honored, and whether or not the employee will be subject
to re-injury, slowing down the medical recovery process, and perhaps making the
practitioner vulnerable to malpractice lawsuits. The employer must respond to
these physician issues by providing medical providers with copies of their policy
on return-to-work. Give the physician an abbreviated return-to-work program
manual, including policy and procedures to be used in communicating with the
physician, as well as copies of Temporary Work Assignments and Essential Job
Function Analyses discussed in Section 3 of the report. Sharing this level of
information will usually result in the establishment of a very cooperative
relationship between the physician and the organization.

Some General Guidelines in the Selection of Providers

Who’s qualified to provide services to injured employees following occupational
injury and illness? Answer: by most state regulations, almost all physicians.
Remember, the road may already be paved by the work done with other
employers in your community. Contact large employers in the area to determine
their experience with local providers. The following parameters are provided to
assist you in the process:
      Survey providers that treat occupational injury and illness as a large
part of their practice. Local reputation is a better judge than credentials at
times. Who wants your business?

      Location, location, location . . . Look for providers that match up well
with your geographical locations, and the areas where your employees tend to
      Availability of services. Have a preference for providers that allow walk-
ins, or same-day appointments, and have a full range of medical services — x-
ray, will do minor trauma, stitches, lab, physical therapy — and have extended
hours of business, including evenings and weekends. Try to find providers that
are open when your employees are working.
      Employees‘ best interests. Look for providers that go beyond just
providing medical treatment. Who are the providers that openly desire
occupational/health business? These are the providers that may offer services
and programs in weight and stress reduction, smoking cessation, back care,
ergonomics and comprehensive wellness programs. These are indicators that
these providers are not only focused on medical treatment, but are focused on
providing preventative health care services as well.
      Be a good consumer. Go, look, smell, experience. The on-site survey is
to see if the telephone marketing message is in synch with the actual day-to-day
services provided. Ask yourself: Would you want to be in this waiting room?
How’s the service? Look at your loss reports to see how much money the
organization is spending on medical services. It helps to get an attitude about the
amount of money you’re spending in the medical community. This should help
you to realize that you’ve got a right to be picky. You are the customer!
      Ask questions. How does this work? What’s your philosophy on return-
to-work? How often do you do follow-up care? How do you refer to specialists?
Which ones? How quickly can an employee be seen on a referral? Do you
automatically notify the employer of procedures/changes? The On-Site Survey
Sheet outlines many of these questions.
      Physical & Occupation Therapy Clinics. Visit and educate yourself as
to their treatment processes and modalities. Will they offer services early and late
in the day to minimize workplace disruption for those employees in the
transitional return-to-work programs? Will they come on-site to solve ergonomic
or workplace issues that would assist in an employee’s recovery? Who have they
provided on-site services to in the past? Get their references.
After completing your on-site survey, select four or five medical providers in each
of the organization’s geographic locations to serve as initial treatment providers
in cases of occupational injury and illness. Publish the medical provider
information in the same area that your workers’ compensation postings are
placed. Provide this information in employee safety trainings.

    Follow up with your employees on the quality of treatment and services they
receive after they have seen these providers. Use the Employee Survey forms in
the resource manual. Contact the physicians to resolve any problems, and assist
the employee in clarifying information given to them by their physicians.
Remember, employees very often will not ask the physicians specific questions
pertaining to their return-to-work, or to the recovery process. The employer can
be an employee advocate, and can assist in getting clarification on medical
issues if requested by the employee, and if the issues are in the realm of return-
to-work/fitness-for-duty. Some organizations further determine the quality of care
by attending the physician visit with the employee. Although you will not
accompany them to the examining room, you can be included at the end when
the physician discusses work status information. You can verbally inform the
physician of return-to-work options, and show your concern to/for the employee’s

Targeted Communication Strategies
     The use of targeted communications is very effective in obtaining medical
information. These are employer developed formats that promote day of
injury/treatment work status information sharing. One method of communicating
with the physician is to provide a prepackaged information packet that the
supervisor initiates, and the injured worker carries to their physician. The
Physician Packet will be fully described in the workbook. This packet is available,
either in a central location, or with the employee’s supervisor or manager. The
packet contains a Work Status Report and a Physician Information Sheet and an
Employee Instruction Card. The information is returned by the employee to their
supervisor following treatment. The Physician Packet can contain a list of
medical providers, their locations and hours to assist in channeling the employee
to highly qualified occupational medicine providers. Remember, the
INTRACORP, 1997 study, reports 90% of employees surveyed indicated they
would follow the employer recommendations for medical providers.9

SIA Study Background
This study was conducted under the California Workers Compensation
jurisdiction. California law allows for employees to pre-designate a personal
physician in writing prior to the injury in order to receive medical treatments from
their physician of choice. Until recent reform pre-designation could include
chiropractic physicians. In the absence of a pre-designated physician, the
employer has 30 days of medical control. The current law continues the practice
of pre-designation, 30 days of employer directed medical control, and the newest
feature of an employer medical provider network (MPN). Sparing the endless
nuances of the MPN regulations, suffice it to say the employer can direct medical
services with the ―state certified‖ MPN for the life of the claim. The injured worker
can request up to three (3) changes of physicians within the medical network per
disputed claim issue and unlimited changes within the network. Against this legal
backdrop, SIA employed the simple but effective principles expounded in the two
aforementioned studies, namely, develop and maintain a good working
relationship with medical providers. SIA, to date, has not embraced the
formalized MPN structure as they have achieved those benefits without written
agreements, discounted fee schedules, and all the trapping/red tape associated
with the MPN.

The issues that faced SIA in developing good working provider relationships
were not unique. Several of SIA school districts are located in small towns and
rural areas where occupational clinics/specialists do not practice. Many
employees living in these remote areas have chiropractic physicians pre-
designated. While issues were not unique, SIA’s in-house nurse resources were.
Unlike, most public agencies, SIA employed case management nurses. This
greatly facilitated the development of working relationships within their local
medical communities.

The SIA criteria for selecting providers were based on the timely access to
qualified occupational medical services to treat the specific injury/illness in
question. The cadre of nurses at SIA, collectively, had long standing
relationships with the area’s occupational clinics and specialists. During the
study period 2000-2005, these provider relationships were enhanced with
frequent meetings, roundtable discussions, and constant exchange of
information. These activities built a trust based on genuine interest in the
employee and employer between SIA, the school districts, and the
physician/clinics. The results benefited all parties. In all case, with rare
exception, the Intake RN and Case Management RN were successful in directing
the employee to these providers, without employee objections. The success of
this endeavor was in large part due to the employee’s relationship with the SIA
nurse. The first encounter occurred during the critical moments following injury.
The initial telephone report to the nurse set the tone for the entire worker’s
compensation process. The dynamics of the nurse injury report process and the
ongoing case management will be explored fully in the study.

Prior to 1999-2000, most of the SIA school districts reported work injuries
telephonically to a nurse. This telephonic report did not embrace a nurse medical
triage process or early intervention return to work. The program in place at SIA
since the early 1990s was called the Field Intervention Nurse (FIN) Program.
The FIN Program primarily focused on the nurse attending the first medical
appointment to initially direct medical care and establish goodwill with the
employee. The FIN Program did not encompass ongoing case management and
early return to work. In 2000, the Early Intervention Nurse (EIN) Program was
established. The hallmark of this program was to incorporate medical triage
services and provide early intervention return to work. The EIN services included
―cradle to the grave‖ case management. The dynamics of the employee-nurse
interchange is at the core of the SIA claims management process. It tends to
shape the interpersonal relationship between the employee and claims
management. The study examined the injury reporting process in an effort to
dissect this important event.

Dynamics of the Nurse Injury Report Process
The nurse injury report line is the first line of defense in controlling medical and
claims costs. It is valuable to examine the telephonic exchange of information
and its impact in the SIA workers compensation program. The telephonic
interview is a four part process:

   1.   Address the Injury
   2.   Brief Medical History
   3.   General Information
   4.   Medical Treatment Decision.

1. Address the Injury
The Intake Nurse initially focuses on the employee’s injury. Typical initial
questions include: tell me what is hurting; what are you doing now—with a
primary purpose being to calm the employee’s anxiety about the injury. Since
the nurse cannot visibly assess the employee’s physical condition, they rely on
verbal cues in the employee’s voice tone to further evaluate the level of
employee discomfort. This is a critical interchange in the life of a claim. The
nurse’s skill in establishing a positive and supportive communication pays huge
dividends in the short and long term. Their role in the medical triage process is
to assess the employee symptoms and advise the employee on self-care and
first aid treatment options. In some cases the nurse recognizes the need for
immediate medical treatment and schedules an appointment during the call. This
portion of the intake is also devoted to obtaining a sequential, factual report on
how the incident happened and witness information. The quality of the
information gathered by the nurse who is experienced in work site operations is
vastly superior to a form completed by the employee and/or supervisor. The
consistency of information obtained by the nurse is vital to their claims
management process.

2. Brief Medical History
After the initial medical assessment and accounting on how the incident
happened, the intake nurse gathers a brief medical history on prior injuries,
injuries to the same body parts and current medications being taken. This
information is useful in further building a positive dialogue and provides essential
claim data. At times typical ―red flags‖ are identified that will require examiner
follow-up. The Nurse Intake Form is provided in the manual which lists ―red flag‖

3. General Information
Following the brief medical history, the nurse gathers general demographic
information to complete the first report of injury.

4. Medical Treatment Decision
The final component of the intake is the decision of whether or not to seek
medical treatment. The nurse will ask the employee, ―Do you feel you need to
see a physician?‖ The medical treatment decision belongs to the employee,
although there are situations where the nurse will strongly encourage the
employee to see a physician. If the employee elects not to seek medical
treatment, the nurse will review symptoms to watch for and follow-up on
employee self-care instructions. Employees are instructed to call back if
symptoms get worse or do not improve within expected timelines. The nurse will
advise the employee on any specific workers compensation requirements. The
incident information will be entered into the claims system database to record the
incident should the employee elect to seek medical treatment at a later date.

SIA nurses believe the sequence of the telephonic interview is important. The
most important goal is to develop a rapport with the employee and address their
injury concerns.

SIA Findings
During the five year period, SIA school district employees reported 7,617
incidents to the nurse injury report line. The intake nurse triaged all calls. During
the period, 2,998 reports resulted in an RN self-care status, 39.36% of all calls.
In a follow-up evaluation at 90 days post call on these RN self-care cases, 94%
remained as incident only, no claim filed. This is strong evidence to the nurses’
ability to assess the appropriate level of care. Additionally, this supports that the
employee had a high satisfaction level with the services of the nurse injury
reporting process. Other factors that support the employee satisfaction include:
 Feedback to the intake and case management nurses from employees—
  overwhelmingly positive according to their antidotal reporting.
 Low claim litigation rates. SIA litigation rates for all claims during the five year
  study period were 7%. California statewide litigation rates average 20 %10

 Low utilization of the right to see a pre-designated physician. SIA staff, nurses
  and claims examiners report a very low (―very rare‖) utilization of a pre-
  designated physician
 Minimal change of physician requests beyond 30 days. SIA examiners, when
  asked about change of physician requests reported the following comments:
        ‖ very infrequent‖
        ‖ fewer than I have ever seen anywhere else‖
         ―one on my caseload‖
Other examiners reported 1 in 20 and 1 in 10 cases. Note: SIA examiners
reported that they feel a frequent catalyst for change in treating MD is directly
related to the claims becoming litigated. The employee obtains an attorney and
the first thing the attorney does is refer them to another MD.

Overall, the Nurse Injury Report Line is very cost effective in avoiding medical
treatments when it is unnecessary. Additionally, the employee understands that
the door is open for call back to the nurse should their symptoms change. The
data gathered on these ―near miss‖ incidents is valuable in protecting the
employee’s right to file a claim and addressing the specific worksite issues that
contributed to the incident. The consistent quality of information gathered
moments after the injury is recognized at SIA as their first line of defense in
controlling all the subsequent claim management events. The loss control and
injury prevention services at SIA in concert with the school districts utilize this
information in their loss prevention programs.

Final Thoughts on Partnering with Physicians
The physician is a key player; they often start & stop the claims process. The
employer must recognize their responsibilities and role to assist in the medical
treatment process. Employers do have an opportunity to develop better working
relationships with their local medical community. Those employers who develop
communication lines with physicians better control their own bottom line. There
are simple, effective strategies outlined in the study and the accompanying
workbook for employers to adopt. At SIA, having trained medical staff in-house is
certainly an enhancement to assist with medical provider relations but not a
requirement for success. The area of provider relations is indeed fertile ground
for employers to further control workers’ compensation costs and enhance
existing employee relations.

                     Section 3- Early Return to Work

In the past fifteen years, various models of return to work programs have
surfaced. There is an undeniable body of evidence that supports the use of RTW
programs to control disability costs. These programs not only provide an
economic opportunity to reduce the employer’s costs but can resolve the
employee’s insecurities surrounding a disability claim. As reported by
INTRACORP, 1997, the primary issues facing employees are related to medical
treatment, financial and job loss, and the emotional issues associated with the
disability. The survey further reported that employees who were satisfied with
their employer’s response to their injury/illness returned to work 50% faster.11 In
other words, organizations that provide programs and information to their
employees at critical points in a disability claim reduce those employee
insecurities. This in turn leads to markedly increased employee satisfaction
levels. Many organizations, after implementing RTW programs, have
experienced significant reductions, 25-50%, in indemnity/time loss payments and
lost days due to workplace injuries. How big is the economic opportunity
presented here?

 According to Day-1 Systems, a disability management firm specializing in RTW
programs, a mid-size public employer, 1,000-1,500 employees, may experience
savings up to 50% reductions in current year claims costs often resulting in
$300,000-$500,000 annually. This represents an even bigger economic
opportunity when you include the development costs of these claims over time.
For many public entities the open long-term claim exposures represent a
foreboding tsunami effect.

 In a related article, ―Evaluating the Practicality of Return-to-Work Programs,‖
(Crawford & Company) the savings formula was reported at 54% of
current workers’ compensation costs. Their savings formula indicated
that the return on investment (ROI) was nine dollars for every dollar
spent by the organization in implementing a RTW program.12 Imagine a
large conference table in your organization stacked with hundreds of
thousands of dollars. Now visualize that you have developed a strategy to
capture/retain 54% of that money. The cost of doing little or nothing is hard to

Let’s examine this on a smaller scale. For individual worker’s compensation
cases, this translates into a return to work 50% faster, with 54% less cost. Every
employee off work on a disability case is at considerable risk for a costly, long-
term absence. The statistic that is often cited is that in a work absence of >180
days, only 10% of those individuals return to their regular job. If true, that is an
alarming statistic. Let’s examine the employer’s response to developing return to
work programs in recent years.

                The Development of Return to Work Programs

Over the past fifteen years, the risk & insurance industry has encouraged
employers to develop return to work programs. These are known as ―light,
modified, transitional, temporary duty‖ programs. The primary function of all
return to work programs is to provide a temporary work site accommodation to
allow the employee to return to work under a physician’s set of work conditions
known as work restrictions. During the same period, physicians and
occupational medicine providers have gotten on board (often required by state
workers’ comp regulation) by providing the medical/work conditions by which an
employee can return to work. The infamous ―light duty‖ slip is being replaced by
exact work restrictions. The medical provider’s shift in thinking from ―off work‖ to
―modified work‖ under work restrictions has come about in large part due to the
employer community’s use of return to work programs.

Today, most occupational medical providers are cooperating with the employer in
return to work issues. The Integrated Benefits Institute reported, April 2002, in a
physician survey that medical providers ―stand ready‖ to assist employers.
       ―The biggest obstacle to physician involvement in RTW is that they seldom
are asked‖.13

 In the same survey, half the physicians reported they ask the employee how
much time off they want and one-third ask how many weeks of disability benefits
are available. These physicians reported that there were several targeted
communications typically missing from the employers. These include detailed
job descriptions of modified work and assurance from the employer that work
restrictions would be honored.14

The often-cited employer complaint that the physician is the source of the
workers’ comp problem seems outdated in the work injury management focus of
today. It is true that some providers are not on board but few occupational
medicine specialists/clinics are not in step with the return to work venue.

There is a significant opportunity for the employer to do some outreach with their
local medical providers. In the absence of these outreach/relationship-building
activities, the physician will take the most conservative approach to return to
work. We have all seen these results, the list of ―cannot do‖: sit, stand, walk,
bend, lift, use hands etc. When the organization takes a different tact with the
medical providers the ―can’t do‖ are replaced by an attitude of ―can do‖. All it
takes is a defined process of transitional /modified duty options, sharing of critical
job demand information and a cooperative approach to communication with the
physician. The results are dialed in. If we take the insurance industry and
medical providers’ support for RTW at face value, then what are the primary
obstacles for organizations in developing return to work programs? Most of the
issues are internal to the organization. The primary obstacle is the
culture/philosophy of the organization surrounding workers’ comp and old

                        Organizational Culture and RTW

Until 1985, the prevailing response by most organizations to return to work was
primarily the ―whole man, no man‖ culture. Employers did not offer temporary,
light, or modified work during the worker’s medical recovery. Many organizations
had policies against return to work unless the worker was 100%, released to full
duty. In response to a looming national worker’s compensation disaster in the
1980s, organizations had to re-think their worker’s compensation programs.
Over the past fifteen years, significant culture change with respect to RTW
programs has taken place.

 Several distinct RTW program models have emerged. The ―whole man, no
man‖ culture is being replaced by the knowledge that return to work is a good
business strategy to reduce worker’s compensation costs, deter system abusers,
and gain work productivity during the medical recovery period. Successful return
to work programs initially developed to control worker’s compensation, have
been extended to control non-occupational disability costs. Many organizations
are developing integrated disability management (IDM) programs with the intent
to reduce overall work absences/costs through use of return to work programs.

                       Types of Return to Work Programs

RTW programs vary in their structure, deployment and performance. The
program variations reflect the organization’s commitment to changing their
culture surrounding return to work. It seems that some organizations responded
to the RTW movement by hastily implementing programs that were not well
conceived or did not fully address the required change. Frequently, they lacked
upper-management support, and continual training within the organization was
absent. These programs quickly fade into the shelves of the organization and are
dubbed ―shelfware.‖ Although any return to work program can be somewhat
effective in returning an employee back to work, the distinctions between
programs are found in their deployment and the resources extended by the
organization to manage RTW. There is no auto pilot function in RTW. To seize
the economic opportunity available, organizations must commit the necessary
resources. As organizations moved from the 100% or nothing standard, their
RTW programs reflected their willingness for organizational cultural change. For
discussion and evaluation purposes, three classifications of RTW programs are
proposed. These are basic, intermediate, and advanced. A tool box graphic will
be used to demonstrate program differences. How big is your organization’s tool
box? The cost of resourcing/upgrading your tool box is minimal in comparison
with the available cost savings.

Basic Model ―Basic Tool Box ―
This program is largely an informal program and usually functions
within the human resources or risk management department. The
structure of this model is selective deployment. Organizations with
basic programs adopt a ―pick and choose‖ philosophy. They are very
selective in offering return to work. Usually the RTW decisions rest at
the departmental level, not at the organizational level. Often there are
departments openly opposed that refuse to return their employees back to work
unless ―fully released‖. The overall program structure has no written return to
work policy or procedures. There is an absence of upper management support
and the overall effectiveness of the program as a loss control tool is insignificant.

These programs are managed loosely and are not staffed/resourced sufficiently
except through a collateral-duty assignment. In this model, if you are a valued
employee working in a supportive department, then you are a likely candidate for
modified duty. These organizations typically do not foster long-term relationships
with local medical providers or get intricately involved with the worker’s
compensation claims management process. Their view of workers‘
compensation is one of compliance not control. For these organizations,
worker’s compensation is largely seen as the cost of doing business.

Intermediate Model         ―Craftsman‘s Tool Box‖
The hallmark of the intermediate model is that the organization has sufficiently
changed its culture to support return to work activities.
Intermediate model programs exist within a ―supportive
services‖ culture. These organizations recognize the need
to work in a supportive manner with the claims management
and medical treatment process although they are not inter-
linked in a collaborative process. The difference is that each
of these stakeholders is doing business as usual while
recognizing the need to support one another’s effort. In a
collaborative process, the employer directs and orchestrates the return to work
process. This will be further examined in the advanced model discussion.
Intermediate model organizations have adopted a formal RTW program usually
characterized by upper management support and written RTW policy &
procedures. Their RTW program development is deployed on a ―case by case‖
assessment. The case by case approach often misses the day of injury early
intervention opportunity. This relates to the services and speed of the employer’s
response on day of injury. There are several factors that affect the day of injury
response. These include how the injury is reported, where medical treatment is
sought, how/when the organization is notified of possible modified duty work
restrictions, and how quickly the employee is returned to work. In many states, if
the worker is off work more than three calendar days, the claim is in an
indemnity/time loss status. Indemnity claims are more costly than ―medical only‖
claims. If the employee is returned to work in modified duty within the three day
window, the claim is in a ―medical only‖ status.

 The employer’s resources committed to managing the RTW process determine
the overall effectiveness of these programs. There is usually an individual whose
duty is to coordinate return to work within the organization, often known as a
RTW Coordinator. The RTW Coordinator serves as a primary conduit of
information between the employee, supervisor, claims management organization
and the medical provider. RTW Coordinators may wear many hats (collateral
duty) or be dedicated to the RTW/disability management process. The
importance of this role cannot be overstated. This is the glue that binds an
effective return to work process. Many organizations under-staff/resource this
role and fail to recognize the importance of this function.

Within the intermediate model there are varying degrees of RTW program
sophistication. Some organizations have developed pre-identified transitional,
modified duty options to accommodate a quicker/smoother RTW decision
process. Some will work actively with their local medical providers to orient the
physicians to the organization’s RTW culture. There is usually an expectation
of return to work in modified duty that is shared by the employee,
supervisor and physician. There may be pockets of resistance in certain
departments but overall the program is effective in reducing workers’ comp costs.
These organizations are usually efficient in getting their workers back in modified
duty but not always timely enough to avoid the claim from becoming an indemnity
claim. Another issue is that employees linger too long in a modified duty status.
The slow return to full duty is a problem for most intermediate program models.

The intermediate model employer may use vendor case management assistance
assigned by the claims management organization. These vendor-based case
management services and outcomes are distinctly different from employer-based
case management. The program cost savings, and overall program
effectiveness, is usually measured by the claims management vendor/broker’s
loss analysis reports. These organizations typically do not have an
event/information database system to record, track, report and evaluate program
effectiveness. There is no systematic employer RTW program evaluation that
would include: looking at stratified losses before and after RTW, average claim
incidence/severity /costs before/after RTW, litigated claims rate/costs and closure
rates before/after RTW. There is an absence of annual program goals and
continued training to all primary stakeholders. The use of targeted
communications to the employee, supervisor, union and physician/medical
providers is sporadic. Initially, these RTW programs produce significant cost
saving during the first 1-3 year period. These results sometimes fade quickly as
the program erodes, personnel changes and the organization shifts focus. The
lack of a continual evaluation and refinement process leads to further erosion of
program effectiveness.

 Advanced Model              ―Mechanic‘s Tool Box‖
Organizations reach an advanced RTW program model through a
process of continual improvement and evolution. This may take a period
of several years. These programs are characterized by a collaborative,
inter-linked services approach. The organizations have evolved from a
case by case approach to a systematic RTW decision process. There is
a 100% return to work expectation akin to the ―zero defects‖ production
orientation. The design of the program is to define an appropriate early
intervention modified duty response for all injury/illness claims of the
organization. This conceptual 100% RTW model like the ―zero defects‖ model
is not always successful, but by design will be effective in most typical
injury/illness cases.

These organizations have refined their relationship to a collaborative level with
respect to claims management and medical services. These employers direct
and orchestrate a multifaceted return to work process. A hallmark of these
programs is a high level of employee satisfaction. As we know, higher levels of
employee satisfaction lead to higher levels of RTW. The RTW decision is
systematic beginning in advance of the injury/illness claim by using targeted
communications, and training to supervisors, medical providers and employees.
The day of injury reporting process is refined through use of a single point of
information gathering from the employee/supervisor. The paperwork or high tech
process is replaced by high touch, a direct contact with an RTW Coordinator
trained in early intervention case management. The role of the RTW Coordinator
is the primary employer conduit of information and decision-making throughout
the life of the claim.

The most critical point in the management of any disability claim,
particularly worker‘s compensation, is day of injury. The activities and
responses of the employer will determine the life span/costs of that claim. In the
advanced model, RTW programs are managed and staffed within the
organization. Their activities direct and support the primary stakeholders:
employer, supervisor, claims management and medical providers. The
organizations have dedicated case management information systems that
support ongoing RTW case management and program evaluations. The
organizations recognize the value of ―owning the data‖ and are not dependent on
vendor data analysis. These employer-based information systems in turn
support a continual evaluation of vendor claims management and medical
services. These advanced RTW programs focus on the critical points of disability
case management. These are defined as:

                       Day of Injury Reporting
                       Early Intervention Response/RTW
                       RTW Case Management

              Day of Injury Reporting
The injury reporting process has been fully reviewed                             in
Section 1 and will not be repeated in this discussion of RTW models. Suffice it to
say; those organizations that recognize this simple function as the gateway
process to overall program success can alter the entire spectrum of their
workers’ comp claims processes.

                      Early Intervention Response: Day 1

As integral as the injury reporting process is, the day of injury early intervention
opportunity is also critical to disability claims management. Return to work
coordination begins with the initial injury report. Advanced RTW model
organizations begin the return to work process day of injury. Employees are
provided targeted communication forms for the medical provider to complete at
the time of the initial medical treatment. These include work status forms and
physician information about the organization’s commitment to return employees
to work. The early intervention response initiated on the day of injury has many
points to connect before the employee can be safely returned to modified duty.
The return to work decision is first predicated on having a physician work status
report. The receipt of a medical work status report on the day of injury/treatment
is essential if the employer is focused on preventing an indemnity/time loss claim.
In 50% of the states, indemnity begins after a three-day waiting period.15 Upon
the receipt of medical work restrictions, the employer must evaluate the
availability of modified duty within the physician’s work restrictions.

In the Advanced model, the organization has numerous pre-
identified transitional, modified duty options available immediately to
encompass the physician’s work restrictions. The employer must
build a deck of cards, in essence, to play on the day of injury. The
modified duty assignments should be able to accommodate almost
any injury/illness situation.

There are endless temporary modified duty assignments at all

                  Temporary Work Assignment

                                    Tasks might be . . .
                                     Part of existing job
                                     Supervisor assistance
                                     Administrative; special projects
                                     Maintenance/p.m., benchwork,
                                     Inventory/sorting/labeling/ordering
                                     Quality; visual tasks
                                     Safety/hazard inspection
                                     Training
                                     Ongoing or periodic/seasonal
                                     One-time only

The resource manual will offer additional training and samples to build the deck
of Temporary Work Assignments. These modified duty assignments are available
for the physician to review if requested. These descriptions include a detailed
breakdown of the physical demands of the assignment. The employee,
supervisor, and physician expect the organization to offer modified duty if the
employee is released to return to work with work restrictions. The targeted
timeline for modified duty return to work is immediate if medically appropriate
work is available. The return to work coordination process includes a discussion
of work restrictions and modified work with the supervisor and employee before
resuming work. Many organizations use a Return to Work Agreement that
reinforces policies and RTW protocols.

In addition, the employer provides the physician a detailed Essential Job
Function Analysis (EJFA) description of the employee’s regular work
                                       assignments. The EJFA provides the
Essential Job Function                 physician with detailed physical/mental
              Analysis                 job demands and work conditions and
    Job Description
                                       serves as the benchmark for a full duty
                     Equipment & Tool Repair Technician
    Job Title: Mechanic
    Employer: Clark County
    Division: Auto Shop
                                       release. Getting an employee back to
    Location: Las Vegas, NV
                                       modified duty immediately is only half the
    Full time, 1 shift                 battle. The progress back to full duty
    40 hours per week, 8 hours per day
                                       really defines program success. Samples
                                       of EJFAs will be included in the resource

                                          RTW Case Management

RTW Coordinator
In the Advanced RTW model the targeted timeline for modified duty return to
work is day of injury. A sense of urgency is required if the organization is focused
on preventing indemnity claims. There are several benchmarks from which to
evaluate the success of an employer’s return to work initiative. At SIA, the most
critical benchmark was to prevent an indemnity time loss claim by returning the
employee to a full modified duty assignment within three (3) days following the
injury/illness. This activity requires the connection of many variables.

 The return to work decision process is greatly facilitated under the Advanced
RTW Program model. There is a ―shared expectation‖ of immediate return to
work. This expectation is achieved through the RTW program implementation
phase and maintained by a uniform response to all comp situations. At SIA, the
program applied uniformly to administrators, teachers, skilled and unskilled
support personnel. Having this shared expectation prevents an employee from
thinking they are being singled out or punished for filing a comp claim. It is vital
that the employee view the process in a positive manner. Therefore, one of the
defining characteristics of a RTW Coordinator is to be an impartial advocate for
the employee and management. The graphic below portrays many of the role
qualities of a RTW Coordinator.

              The Return-to-Work Coordinator must be part —

        Detective                    Confessor                 Psychologist

         Pacifier                   Negotiator                Jack-of-all-trades

                            The role often demands —
                                  Creativity akin to Edison
                                  Patton’s grit and determination
                                  Gandhi’s patience
                                  Doc Welby’s tact and diplomacy
                                  Mother Teresa’s peacefulness
                                  Annie Oakley’s eye for the target
                                  Houdini’s art of escape

Overall, the RTW Coordinator’s role is to manage the entire process of the
employee’s entry into modified duty and the eventual program exit by returning
the employee to full duty. While it is true the physician controls the work status
decision, the RTW Coordinator can greatly influence the entire process. Their
role is to openly communicate with the physician and their patient throughout the
return to work process. This can include frequent conversations with the
physician and occasionally meeting with the physician to problem-solve issues in
return to work. The RTW Coordinator must be adept in a variety of skills/abilities.
High on the list include: good listening skills, ability to communicate with
individuals with varying socio-economic backgrounds and cultures, excellent
problem-solving abilities and the ability to think fast on their feet. Equally high on
the list is attention to detail, effective writing skills and of course, follow through.
A jack-of-all-trades as the saying goes. At SIA, the return to work case
management function was handled by a nurse. This certainly enhanced
communications with the physician although medical credentials are not a
requirement for RTW case management success. The skill set of an effective
RTW Coordinator can vary. It is desirable to have experience in workers’ comp,
disability management, safety or human resources. This cuts down the learning
curve. A RTW Coordinator, once seasoned, is a very valuable asset to the
organization. The return on investment for an effective RTW program is
significant. The RTW Coordinator is the glue that binds the process together.

RTW Protocols
What is the most effective way to manage the RTW process once you have
the employee back to modified duty? Establishing RTW protocols is a
hallmark of an advanced program. The goal is to effectively manage the RTW
program according to program guidelines based on specific protocols. An
effective RTW program will require RTW case management protocols
(specific timelines to evaluate the progress of the employee’s return to full
duty) that the RTW Coordinator must maintain. The RTW program structure
is essential to define. What are the entry/exit points in a return to work
program? How will the organization define RTW progress? What is the
maximum amount of time allowed in modified duty; is it specific days or is
there a situational criteria applied? Most claims examiners would not want the
employer to put an employee in an off work/ indemnity status, removing them
from modified duty. Yet, modified duty cannot go on forever as this can be
viewed as a permanent accommodation. In the accompanying resource
manual, sample RTW Protocols will be provided. In most organizations, RTW
program development must be viewed as an evolving process. The point
where SIA started in 2000 is not where it exists today. The issues
encountered will be fully presented in the following section, ―SIA Structured
Return to Work Program‖.

                 The chart below will offer a comparison of the RTW program models:

                                                             Basic             Intermediate              Advanced
                    Best Practices
                 RTW PHILOSOPHY                         Selective RTW           Supportive         Collaborative Services
What is the organizational commitment level to RTW?         Model             Services Model               Model
                                                        Pick & Choose          Case by Case           Systematic RTW

                                                           Informal                Formal               Systematic
Written Policy & Procedures                                   No                 Sometimes                  Yes

Written RTW Agreements                                        No                 Sometimes                  Yes

Targeted Communications to Stakeholders                       No                 Sometimes                  Yes

Pre-identified Modified Duty Options                          No                 Sometimes                  Yes

Essential Job Function Descriptions/Job Analysis              No                    Yes                     Yes

Management/Supervisory Training                               No                    Initial               Ongoing

Union Orientation                                             No                 Supportive            Collaborative

RTW CASE MANAGEMENT                                   Collateral duty if at   Collateral duty or      Dedicated staff
Employer/Vendor-individual assigned to manage RTW             all              dedicated staff
and coordinate activities among stakeholder.

Information/case management software system           Vendor-based if at      Typically, case         Employer system,
                                                             all              tracking diaries     tracking/reporting case

―CRITICAL POINTS‖ FOCUS                                  Compliance                 Early             Integrated focus
1.Day of Injury Reporting:                                 focus                intervention         w/claims, medical
                                                       multiple points of           focus            treatment & RTW
                                                      data collection, not    single or multiple    uses single, point of
                                                        always timely           points of data        data collection,
                                                                                  collection        uniform/consistent
2. Early Intervention Response: Immediate RTW                None                Not usually                Yes
Defined return to work protocols                              No                 Not usually                Yes

                                                      Minimal outreach           Attempts to       Collaborative, ongoing
3. Medical Provider Partnering                         by employer to         channel medical      relationship, employer
Employer channels/directs employee to occupational       physicians           treatment, rarely      constantly looks at
medicine providers or within occupational networks.                               evaluates            outcomes and
                                                                                  outcomes            participates with
                                                                                                    provider as a partner

Prior to 2000, most of SIA’s twenty eight school districts in their comp pool did not
participate in a formalized return to work program. Many of the districts permitted
modified duty return to work but lacked policy and procedures and a systematic

A Structured Return to Work (SRTW) Program was implemented during the 2000-2001
school year. SIA contracted with Dennis Chandler, Day-1 Systems, to assist their staff
in developing an integrated process combining the nurse injury report line, return to
work, and claim management. At that time, SIA had a staff of three nurses that were
assigned largely to medical management functions. The nurses’ role was redesigned to
include a medical triage process with the injury report line and coordinating an early
intervention return to work effort. Nurses were assigned various districts to manage the
return to work process and to provide medical case management services.

The SRTW Program design had to span the
differences in the twenty-eight school districts. SIA               Return-to-
                                                                    Return-to-Work Process
prototyped the SRTW Program at seven selected
districts representing differences in size of operations
and span amongst geographic areas containing urban               Work Injury

and rural districts. All twenty-eight districts utilized
the nurse injury report line, replacing their customary
process of a paperwork form. One of the issues to
resolve was the lag time between injury/illness
occurrence and notification to claims management.
The SRTW Program was fully implemented at all                                  Employee/Supervisor
districts within a seven month period during 2000-                                 Call Nurse
2001.                                                                  Report Injury
                                                                       Triage Medical
                                                                       Complete Report
                                                                       Immediate notification/reports to all
The initial challenge encountered was to get all                       parties
twenty-eight school districts on the same page as it
pertained to setting ―a shared expectation of return to
work‖. Meetings were conducted throughout each
district to provide training to administrators, union
representatives, supervisors and employees. SIA
used targeted communications that included color
worksite posters which portrayed the injury reporting
                                                                                    Nurse Employee to
and return to work process. Employees received                                      Medical Treatment
injury reporting instructions on wallet cards and
brochures detailing the SRTW Program. The nurse                                Physician completes work status
assigned to the district began to actively liaison with                        Employee returns work status
                                                                               report to employer.
district management. Each district had a workers’
compensation liaison that would receive notification
from the EIN on new injuries and updates on cases in
modified duty.

SIA was in first position to receive injury notification via the nurse report line and the
initial medical work status; therefore, constant/ongoing communication was required
between the WC liaison and the nurse. The WC liaison was notified and participated in
the return to work process. As reported earlier, SIA received 4,627 claims during the
five year period between FY-01 thru FY-05. Medical Only (MO) and Medical Only
Restricted Duty (MO-RD) claims comprised 79% of claims. The MO-RD
claims accounted for 1,209 cases, 26% of all claims. These cases involved
physician work restrictions placed on the employees which precluded a full
duty return to work. If these employees had not returned to a full modified
duty work assignment within 3 calendar days, these cases would result in
an indemnity time loss status. This is strong evidence to support the
effectiveness of an early intervention process by the nurse working with individual

                               Employee/Supervisor & RTW

                             Review work status report
                             Assign modified duty/TWA
                             Complete RTW agreement

In a follow-up evaluation conducted during the study, these cases remained in a
medical only status ninety days later. This evaluation looked at MO/RD cases during
the FY 03-FY 05. During this three year period, 691 cases were classified MO/RD, 637
(92%) remained in a medical only status 90 days later. Not only was SIA effective in
preventing the initial indemnity time loss, but they resolved those cases long term in a
medical only status. During FY 01-02 for example, 47% of all MO/RD cases closed with
an average cost per claim of $501.00.

The basic principles of SIA SRTW are:                         Monitor Employee‘s
 Systematic return to work process to evaluate each          Progress to Full Duty
  workers’ comp case for early return to work within 1-
  3 days following injury.

 A shared expectation on the part of employees,
  supervisors, district management, and physicians
  that supports early return to work.

     Pre-identified modified duty options that ―stand ready‖ to be utilized for return to work.
      The SRTW Program identified over 100 Temporary Work Assignments available
      throughout all classifications.

     Dedicated Return to Work Coordinator to manage, problem solve, and report on cases
      in modified duty.

     Case management information system to track, diary, and report case management

     Continual training throughout all districts on the EIN/SRTW Program.

    Many of the initial challenges were resolved during the implementation period. Several
    managers and supervisors opposed the concept of ―light duty‖. Much of the opposition
    stemmed from bad past practices or problem cases. The message was simple---a well
    managed return to work process saves time and money. California schools, like most
    throughout the US, are always in serious budget shortfalls. The workers compensation
    costs in California are escalating significantly. Badly needed resources were being
    funneled to fund workers compensation. A top-down commitment was obtained in all
    districts. This marked the beginning of significant changes in the SIA comp program.
    The nurse medical triage service at the initial telephonic report and the formalized RTW
    program were the core foundation processes. The overall lessening of claims provided
    by these initial services enabled a re-marshalling of claim management staff.

    During this five year period, SIA committed to an ongoing forensic analysis of their
    workers’ compensation data. SIA developed a series of user-friendly management
    reports/charts/graphs that provide each district an accurate picture of their specific
    workers compensation program. In addition, since this is a self-insured pool,
    reports/charts/graphs show each district’s performance as measured with other district
    pool members.

RTW PHILOSOPHY-Prevent lost time claims with an immediate (day of injury) focus on returning the
  employee to medically appropriate, productive modified duty.

Written Policy & Procedures- See examples in Day of Injury Study Resource Manual
Written RTW Agreement- See examples in Day of Injury Study Resource Manual
Targeted Communications to Stakeholders- Worksite Poster, Employee Program Brochure, Wallet cards-
  See examples in Day of Injury Study Resource Manual
Pre-identified Modified Duty Options- Has developed 125 Temporary Work Assignments throughout all
  operations to be utilized for immediate return to modified duty- See examples in Day of Injury Study
  Resource Manual

Essential Job Function Descriptions/Job Analysis-Has developed physician-friendly (one-page) job demands
  analysis to provide the physician as benchmark for full duty return to work and fitness-for-duty evaluations-
  See examples in Day of Injury Study Resource Manual
Management/Supervisory Training- At initial program implementation, annually at the larger districts. SIA
claims & EIN/STRW staff offer ongoing training at the start of each school year.
Union Orientation-Worked with several union representatives during program implementation, no issues

Site Comp Liaison- Each district has an assigned individual that handles the comp issues in the district. This is
a collateral duty assignment, usually they have district payroll or human resource functions as their primary

                                               RTW Conclusions

    First, a significant economic opportunity exists for organizations to control worker’s
    compensation and disability costs through the use of RTW programs. This fact has
    been firmly established and widely proven throughout all employment sectors. The
    extent of the economic opportunity varies from organization to organization. The
    essential ingredient is willingness to change the organizational culture to support RTW
    activities and the commitment of the necessary resources to ensure success.

    All too many organizations have hastily crafted and under-resourced their return to work
    initiatives. These half-efforts did not go the distance for an effective performing return to
    work program. Effective RTW programs are multi-faceted and require a long-term
    commitment for continued success. These programs address many of the root cause
    issues in workers’ compensation claims. Many of these issues lie in the relationship
    between the employer, employee and the worker’s compensation system.

    Too many studies have reached the same conclusion: this ―no fault system‖ is really a
    ―your fault system‖. Comp is a system where cooperative efforts of the primary
    stakeholders are often minimized by adversarial overtones. The best way to work with
    attorneys is only when all your best efforts have failed. Cool Hand Luke summed it up,
    ―What we have here is a failure to communicate!‖ RTW Programs are founded on
    establishing communication lines between the stakeholders. This will require the
    employer to take the lead in this process.

    Success in the RTW endeavor is guaranteed if you include the right ingredients. As
    with all business problems, find a mentor or an organizational model and blend/refine it
    within your organization. Then resource it properly and stay the course. When you have
    implemented an effective RTW process, mind the process, mend the problems.

                           Section 4 Final Conclusions

The Day of Injury Study serves as a significant project in demonstrating the power of the
employer’s role in workers’ comp. Too few employers recognize the full significance of
early opportunities to control comp costs. At Schools Insurance Authority, their focus is
now refined to follow the money trail. What are the key cost drivers in comp? Sloppy
processes, sloppy practices, and an overextended staff, significantly contribute to the
problem. The other driver is believing that you can’t do anything about it. This leaves
many organizations staying the course on this slippery slope.

What was learned at SIA over the past 5-6 years is that organizations can dig out of
sizeable holes. It all starts with defining the problems and implementing corrective
actions. Workers’ comp is just like any business problem. With good science/rationale to
derive at good models, diligent effort and a dedicated team, the problem will cease over
time. The key is where to apply the effort. The Day of Injury is the most important play
for the organization to call.

The Day of Injury Study and the                       DAY of INJURY
resource manual offers entities a
detailed play book. SIA is willing to                      The most important
let you come and stand on their                              play to execute.
sidelines and learn from their
coaches. You need only to get your                        The employer’s response
head in the game and call the right                          on the day of injury
plays.                                                   significantly determines the
                                                          nature, duration, cost and
                                                            eventual outcome of a

 Glen-Roberts Pitruzzello, The High Cost of Delays, Findings on a Lag-Time Study (The Hartford Financial
Service Group, Connecticut: 2000) 1-5.
 INTRACORP, A Study of Injured Workers and Their Experiences with the Worker’s Compensation System,
Communication, Concern, Caring, Surprisingly Simple Keys to Effective Worker’s Comp Programs (INTRACORP,
Philadelphia: 1997) 1-24.
    M. Knott, City of Little Rock Workers’ Compensation Report (Little Rock, AR:2005) 1-4.
    P. Binsfeld, Company Nurse™ Report (Scottsdale, AZ :2005) 1.
 Integrated Benefits Institute(IBI), Physicians Managing Disability: Opportunities and Constraints (San Francisco:
IBI 2002) 1.
  Nicholas Pace, Improving Dispute Resolution for California’s Injured Workers, Rand Study (Santa Monica: Rand
     INTRACORP 14-17.
  Patricia F. Helve, Evaluating the Practicality of Return to Work Programs (Crawford & Company, Atlanta, GA,
1993) 1-10.
      IBI 1.
      IBI 1.
     U.S. Chamber of Commerce, Analysis of Workers’ Compensation Laws (Washington D.C.:1997) 39-41.


1. Full Cost Study, Integrated Benefits Institute, San Francisco, CA Study, 2001.

2. Physician’s Managing Disability: Opportunities and Constraints, Integrated Benefits Institute,
   San Francisco, CA, Study April 2002.

3. Worker’s Compensation Costs Rising across the Nation,, National Academy of
   Social Insurance (NASI), 2003.

4. Niklas Krause, M.D., Lisa K. Dasinger, Ph.D., and Andrew Wiegand, M.P.P.,, Modified Work
   and Return to Work: A Review of the Literature, report prepared for the Industrial Medical
   Council of the State of California and the California Commission on Health and Safety and
   Worker’s Compensation, Berkeley, CA, August, 1997.

5. Karen L. Andaiman, ‘First Call’ System Saves Worker’s Comp Dollars, Business Insurance,
   September 15, 2003.

6. Patricia F. Helve, Evaluating the Practicality of Return to Work Programs, Crawford &
   Company, Atlanta, GA, 1993.

7. The Disability Experience, What Helps and Hinders Return to Work, IntraCorp, Philadelphia, PA,
   study, 2001.

8. A Study of Injured Workers and Their Experiences with the Worker’s Compensation System,
   Communication, Concern, Caring, Surprisingly Simple Keys to Effective Worker’s Comp
   Programs, IntraCorp, Philadelphia, PA, Study 1997.

9. Kenneth Mitchell, Ph.D., How to Prevent Light Duty as a Career Path!, Unum Provident
   Corporation, Chattanooga, TN, 1999.

10. Bureau of Labor Statistics Data, U.S. Department of Labor, , Occupational Injury
    and Illness Data 2001.

11. Employer Time-Off and Disability Programs, William M. Mercer, Incorporated and Marsh USA
    Inc., Survey, 2000.


Description: Medical Claims Management document sample